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481 Cards in this Set
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A nurse is caring for a client of a different culture. The nurse is not familiar with the customs of this particular client and becomes disturbed when the client's spouse makes all the decisions about care and treatments. The nurse's reaction is an example of which of the following?
A) Judgment B) Inference C) Evaluation D) Opinion |
D
Opinions are beliefs formed over time and include judgments that may fit facts or be in error. In this case, the nurse may not understand that culturally, this may be very appropriate and fitting for this client. If this is the case, the nurse should not become disturbed by the spouse's attention. Inferences are conclusions drawn from the facts, going beyond facts to make a statement about something not currently known. Judgment is an evaluation of facts or information that reflects values or other criteria; it is a type of opinion. Evaluation is considering the results or outcome. |
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A nurse is being questioned by the parents of a client whose physician ordered a battery of invasive tests. They are wondering why their child should have to go through all the pain and discomfort of these studies. The nurse is not familiar with the situation and has just come on duty for the evening shift. A limited report was given by the previous shift. The nurse understands that the child is stable at this time and has no pain, but the nurse has not been able to review the chart or do an initial assessment at this point. The best response by the nurse is:
A) "Your child's doctor is the best there is. I don't see why you wouldn't follow his advice." B) "I'm not sure I can answer your question just now." C) "It's a good idea to listen to what your physician wants." D) "Maybe you should get another opinion if you're not comfortable with your doctor." |
B
Suspending judgment means tolerating ambiguity for a time. If an issue is complex it may not be resolved quickly and judgment should be postponed. In this case, the nurse just doesn't have enough information to give a good answer to the parents. For a while, the nurse will need to say, "I don't know" and be comfortable with that answer. Telling the parents to agree with the physician before the nurse knows all the facts might be premature, even if he is the best physician in the area. It would also be premature to tell the parents to get another opinion. Nurses should not give advice or counsel, merely information. |
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A client has been using the call light routinely throughout the evening. Upon entering the room, the nurse observes the following details. Organize them according to priority sequencing (1 is first priority; 6 is least priority).__________ Family is at bedside.<__________ The IV pump is running on battery.__________ ECG monitor shows tachycardia.__________ Client is pale and restless.________ O2 tubing is not attached to wall regulator.__________ Bedding is damp and soiled.
A) 1,3,6,5,4,2, B) 5,3,1,2,4,6 C) 6, 4, 2, 1, 3, 5 D) 6,1,4,2,3,5 |
C
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The nurse is reviewing the client care plan and checking the quality of the nursing diagnosis statements. Criteria to use for guidelines in formulating nursing diagnoses include which of the following? (select all that apply)
A) stated in terms of a need B) nonjudgmental statements C) Word the diagnosis specifically and precisely D) Must be legally advisable E) cause and effect are correctly stated |
C, D, E
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A nurse educator senses that a student has been struggling with clinical skills learned in lab. In the clinical area, this student is usually lagging behind and seems to be involved when the other students have opportunities to perform some of the tasks. The educator pairs the student with a particularly outgoing staff nurse who has a number of unique clients with a variety of treatments and cares. The educator is utilizing which type of problem solving?
A) Experience B) Intuition C) Research process D) Trial and error |
B
Intuition is the understanding or learning of things without the conscious use of reasoning. It is also known as the sixth sense, hunch, instinct, feeling, or suspicion. In this case, the educator has a sense that the student is struggling, though there are no real facts to support it. Experience is part of intuition, but by itself, not a particular way to problem solve. Trial and error uses a number of approaches until a solution is found, which is not the case here. Trial-and-error methods in nursing care can be dangerous because the client might suffer harm if an approach is inappropriate. The research process is a systematic, analytical, and logical way to problem solve. |
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A client comes into the clinic with complaints of "extreme" low back pain after helping to move a heavy object. The client is pale and diaphoretic and walks bent at the waist. Before taking vital signs, the nurse projects that the blood pressure as well as heart rate will be elevated. This is an example of which of the following?
A) Fact B) Judgment C) Inference D) Opinion |
C
Inferences are conclusions drawn from facts, going beyond facts to make a statement about something that is not currently known. In this case, acute, severe pain will most likely cause the blood pressure as well as pulse rate to be elevated as the body's response to the painful experience. Fact can be verified through investigation. In this case, fact would be the elevated pulse and blood pressure readings. Judgment is evaluating facts and information that reflect values or other criteria; it is a type of opinion. Because the nurse understands the pathophysiology of pain, thinking about changes in vital signs is more than a judgmentit is an inference. Opinions are beliefs formed over time and include judgments that may fit facts or be in error. |
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The student nurse is learning the Taxonomy II nursing diagnoses system. This system is coded according to which of the following axes? (Select all that apply.)
A) Gordon's health pattern groupings B) Time C) Gender D) Age E) Health status F) Unit of care |
B, D, E, F
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A nurse is performing an initial assessment on a new admission. Which of the following is part of the database?
A) Reports from physical therapy the client received as an outpatient B) Documentation of the nurse's physical assessment C) A list of current medications D) Information about the client's cultural preferences E) All of the above |
E
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The nurse has formulated a nursing diagnosis of Impaired skin integrity related to poor hygienic practice, secondary to current living conditions. Which of the following data would support this diagnosis?
A) Skin is dry, cracked B) One large with several smaller open, ulcerated areas on right leg C) Clothes are soiled D) Client has obvious body odor E) All of the above |
E
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A nursing student is learning how to implement the nursing process in the clinical area. The purpose of the diagnosis phase includes which of the following? (Select all that apply.)
A) Develop a list of problems B) Identify client strengths C) Develop a plan D) Specify goals and outcomes E) Identify problems that can be prevented |
A, B, E
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A nurse is checking over the past charting of the previous shift, paying special attention to how a particular client responded to nursing interventions throughout the day. The nurse is caring for this client and wants to see what has been effective, as well as what didn't work. This nurse is utilizing which of the steps of the decision-making process?
A) Set the criteria B) Evaluate the outcome C) Implement D) Examine alternatives |
B
In evaluating, the nurse determines the effectiveness of the plan and whether the initial purpose was achieved. In this situation, the nurse wants to determine what worked on the previous shift and what didn't. This will help with deciding on interventions for the client during the shift. Setting criteria is based on three questions: What is the desired outcome? What needs to be preserved? What needs to be avoided? Examining alternatives ensures that there is an objective rationale in relation to the established criteria for choosing one strategy over another. In this case, the nurse is evaluating the previous nurse's alternatives, not choosing new ones. Implementation is putting a plan into action. |
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The nurse has just completed an admission interview with a new client. Which response by the nurse is an example of a remark used during the closing phase of the interview?
A) "Tell me more about how you feel." B) "Is there anything you're worried about?" C) "I'm going to set up your physical assessment now. Do you have any questions?" D) "Could you give examples of what types of other treatments you've had?" |
C
Closing the interview is important for maintaining the rapport and trust between the client and nurse as well as to facilitate future interactions. The closing should contain an offer for questions, conclusions, plans for the next meeting, and a summary to verify accuracy. The other options are what would be part of the body of the interviewquestions designed to gather the most information about the situation. |
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A nurse educator assigned students an activity to implement Socratic questioning in their daily lives. Which of the following is a question about reason using this technique?
A) "What makes you think cramming for a test is an ineffective way to study?" B) "If you didn't study for your test, what is the probability you will fail?" C) "If you study all the unit outcomes, what effect will that have?" D) "What other ways of studying could you implement?" |
A
Socratic questioning is a technique one can use to look beneath the surface, recognize and examine assumptions, search for inconsistencies, examine multiple points of view, and differentiate what one knows from what one merely believes. Questions about evidence and reason focus on just that (e.g., what evidence is there, how do you know, what would change your mind). Asking about ways to study would be a question about the problem (studying). Asking about the effects of studying is questioning about implications and consequences. |
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A nurse who just moved from an urban area to a sparsely populated rural area understands that certain customs and practices the nurse is familiar with may be quite foreign to the people in the new area. This nurse is practicing which of the attitudes of critical thinking?
A) Fair-mindedness B) Intellectual humility C) Intellectual courage to challenge the status quo and rituals D) Insight into egocentricity |
D
Critical thinkers are open to the possibility that their personal biases or social pressures and customs could unduly affect their thinking. They actively try to examine their own biases and bring them to awareness each time they make a decision. Understanding that how things were done and what practices were common may be completely different in the new surroundings is an example of the nurse implementing this attitude. Fair-mindedness means assessing all viewpoints with the same standards and not basing judgments on personal or group bias or prejudice. Intellectual humility means having an awareness of the limits of one's own knowledge. Intellectual courage to challenge the status quo and rituals is taking a fair examination of one's own ideas or views, especially those to which one may have a strongly negative reaction. |
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The nurse is performing a dressing change for a client and notices that there is a new area of skin breakdown near the site of the dressing. On closer examination, it appears to be caused from the tape used to secure the dressing. This would be an example of which phase of the nursing process?
A) Evaluation B) Diagnosis C) Implementation D) Assessment |
D
Assessment is the collection, organization, validation, and documentation of data. Assessment is carried throughout the nursing process, as in this case. Even though performing the dressing change is implementation, noticing the new skin breakdown is assessment. Diagnosis is identifying the client's response to the problem. Implementation is what the nurse does to help the client reach a goal, and then the goal is evaluated. |
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A student nurse who claims to be very uncreative doesn't understand why it is necessary to learn and develop new ideas in the clinical area. The best response by the nurse educator is:
A) "Creativity allows unique solutions to unique problems." B) "You'll get bored if you don't learn to be creative." C) "Not all your answers are going to be from your textbook." D) "Creativity makes nursing more fun." |
A
Creativity is thinking that results in the development of new ideas and products and is the ability to develop and implement new and better solutions. When nurses incorporate creativity into their thinking, they are able to find unique solutions to unique problems. Creativity does make the nurse look beyond the answers found in the text, but it also brings originality and individuality to nursing. The other options listed are not really explaining the best reason creativity is a major component to critical thinking. |
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A nurse enters the room of a critically ill child and has a sense that "something" isn't right. After performing an initial physical assessment and finding that the child is stable, the nurse continues to perform a check of all the lines and equipment in the room and finds that the last IV solution hung by the previous nurse was not the correct solution. This nurse was utilizing which method of problem solving?
A) Intuition B) Trial and error C) Judgment D) Scientific method |
A
Intuition is the understanding or learning of things without the conscious use of reasoning. It is also known as sixth sense, hunch, instinct, feeling, or suspicion. Clinical experience allows the nurse to recognize cues and patterns and begin to reach correct conclusions using intuition. Finding no cause for concern in the physical assessment of the client, the nurse is not satisfied and continues to assess the client's surroundings, finding the error. Trial and error is solving problems through a number of approaches until a solution is found. Judgment is not part of problem solving. The scientific method requires that the nurse evaluate potential solutions to a given problem in an organized, formal, and systematic approach. |
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During an initial interview, the client makes this statement: "I don't understand why I have to have surgery, I'm really not that sick or in pain right now." The nurse's best response is:
A) "I think these are things you should be asking your doctor." B) "What kind of questions do you have about your surgery?" C) "Have you had surgery before?" D) "It's OK to be worried. Surgery is a big step." |
B
The nurse should use a combination of directive and nondirective approaches during the interview to determine areas of concern for the client. Simply noting the concern, without dealing with it, can leave the impression that the nurse does not care about the client's concerns or dismisses them as unimportant. Passing the questions off for the doctor would do the same. A closed question (Have you had surgery before?) does not allow the client to offer much information, besides yes/no or one-word answers. |
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A nurse continues to question the practice of administering rectal suppositories to residents in a long-term care facility at bedtime, rather than earlier in the day. When told that this is the best time for staff and that's the routine that has been practiced for a long time, the nurse continues to research whether there would be a better time, especially in the best interest of the residents. This nurse is practicing which of the critical-thinking attitudes?
A) Integrity B) Curiosity C) Confidence D) Perseverance |
B
The internal conversation going on within the mind of a critical thinker is filled with questions. The curious nurse may value tradition but is not afraid to examine traditions to be sure they are still valid, as in this case. This nurse is asking valid questions. Confidence comes from cultivating reasoning and examining arguments. In this case, the nurse did not reason anything out, but is still asking questions. Perseverance happens from determination in clarifying concepts and sorting out related issues, in spite of difficulties and frustrations. This nurse is still asking questions, not making any changes in spite of difficulties or frustrations. Integrity requires that individuals apply the same rigorous standards of proof to their own knowledge and beliefs as they apply to the knowledge and beliefs of others. |
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A nurse is reviewing the problem list he has compiled with a client and the client's family. The nurse is also relating the various diagnoses he has formulated to this client, then asking for input from the client and family. The nurse is utilizing which of the following to minimize diagnostic error?
A) Understanding what is normal vs. what is not normal B) Verifying C) Basing diagnoses on patterns D) Consulting resources |
B
The nurse, while taking the information and collecting data, begins to hypothesize possible explanations of the data and then realizes all diagnoses are only tentative until they are verified. The client and family should be included in the beginning and also at the end of the diagnostic process to verify the nurse's diagnoses. Nurses must apply knowledge from various areas to recognize cues and patterns to understand what is normal and not normal. This comes from principles of chemistry, anatomy, and pharmacologynot the client or the family. Both novices and experienced nurses should consult appropriate resources whenever in doubt about a diagnosis. Professional literature, colleagues, and other professionals are all appropriate resources. Diagnoses should be based on patterns and behavior over time, not an isolated incident. |
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A nurse educator has always believed that lectures with focused outlines are the best way to present theory content in class. A colleague who teaches the same group of students, but a different subject, utilizes group work and in-class activities to teach difficult content and finds that students perform as well, or better, on their tests. The first educator in this situation is starting to rethink her position. This is an example of which of the following?
A) Humility B) Integrity C) Fair-mindedness D) Perseverance |
B
Intellectual integrity requires that individuals apply the same rigorous standards of proof to their own knowledge and beliefs as they apply to the knowledge and beliefs of others. Trying new teaching techniques in the hope that students might respond positively shows that the first educator is willing to question her own practices, just as she would question those of another. Perseverance is determination that enables critical thinkers to clarify concepts and sort out related issues, in spite of difficulties and frustrations. Fair-mindedness is assessing all viewpoints with the same standards and not basing judgments on personal or group bias or prejudice. Intellectual humility means having an awareness of the limits of one's own knowledge. Critical thinkers are willing to admit what they do not know, seek new information, and rethink their conclusions in light of new knowledge. |
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The nurse, after formulating several diagnoses for a client, does not understand the reason for some of the discrepancies in the client's lab values and diagnostic tests, when comparing to norms and standards. Which of the following is the best action of the nurse?
A) Improve critical-thinking skills so answers come more easily. B) Consult other professionals and colleagues. C) Compare all findings to the national norms and standards. D) Verify the information with the client. |
B
Both novices and experienced nurses should consult appropriate resources whenever in doubt about a diagnosis. Professional literature, nursing colleagues, and other professionals are all appropriate resources. Verifying the information with the client would be inappropriate since the information does not come from subjective data, rather from testing and lab values. The nurse already has compared the findings to the norms and standards. Critical-thinking skills help the nurse be aware of and avoid errors. This comes with experience and is a learned and practiced process. |
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A rehab client has orders for active range of motion exercises to her shoulder following a stroke. The client doesn't like to do these because they are uncomfortable and she can't understand "what good they will do anyway." Which of the following statements by the nurse demonstrates the critical-thinking component of creativity?
A) "You'll only get worse if you don't do these exercises." B) "Your physician wouldn't have ordered these if they weren't important." C) "As soon as you get these into your routine, you'll feel better." D) "Here's a marker. See how many circles you can make on this board in 10 minutes." |
D
Making the exercise routine into something morelike a game, or drawing a picture, or even "decorating the walls," for examplewould raise a challenge to the client, take the focus off the why, and still achieve the end result. Explaining the rationale for doing or not doing the exercises is not using creativity. It is merely explaining the reason. |
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A new graduate nurse learns a quicker way to set up and initiate an IV. This graduate nurse still follows safe practice, but implements changes that help with time management. This nurse is practicing which of the attitudes of critical thinking?
A) Independence B) Intellectual courage to challenge the status quo or rituals C) Confidence D) Integrity |
A
Nurses who can think for themselves and consider different methods of performing technical skillsnot just the way they may have been taught in schooldevelop an attitude of independence. Courage to challenge the status quo comes from recognizing that sometimes beliefs are false or misleading. Integrity requires that individuals apply the same rigorous standards of proof to their own knowledge and beliefs. Critical thinkers believe that well-reasoned thinking will lead to trustworthy conclusions. They cultivate an attitude of confidence in the reasoning process and examine emotion-laden arguments using the standards for evaluating thought. |
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A nurse is taking an admission history from a client who is easily distracted and offers much information about his health and social history. Although careful to document what the client relates, the nurse sorts out the relevant data to determine the best nursing care for this client. This nurse is practicing which attribute of critical thinking?
A) Context B) Reflection C) Time D) Dialogue |
B
Reflection involves being able to determine what data are relevant and to make connections between that data and the decisions reached. Context is an essential consideration in nursing since care must always be individualized, taking knowledge and applying it to real people. Dialogue, which need not involve other persons, refers to the process of serving as both teacher and student in learning from situations. Time emphasizes the value of using past learning in current situations that then guide future actions. |
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A client comes into the emergency department with a non-life-threatening wound to the hand that will require stitches. The department is quite busy with other clients, their families, and other people in the waiting room. The best way for the nurse to conduct an interview with this client is to:
A) Have the client wait until the department quiets down, since the wound is not too serious. B) Make sure the client's back is to the rest of the room so as not to be heard by passersby. C) Tell the client to wait in the waiting room and fill out the paperwork. D) Draw curtains around the client and nurse to provide as much privacy as possible. |
D
The interview setting should be in a well-lighted, well-ventilated room that is relatively free of noise, movements, and distractions in order to encourage communication. The interview should also take place in an area where others cannot overhear or see the client if possible. In this situation, at least pulling a privacy curtain will help keep the client from view of others in the department. Merely making sure the client's back is to the rest of the room is not as acceptable. Having the client wait may cause an unnecessary delay in treatment. |
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A client has been admitted for acute dehydration, secondary to nausea and diarrhea. When is the best time for the nurse to conduct this client's interview?
A) When the family is available to help B) After the client has been medicated C) After the client has settled in and been oriented to the room D) As soon as the client gets to the floor |
C
Interviews should be planned when the client is physically comfortable and free of pain, and when interruptions by the family are minimal. After the client has been oriented to where the bathroom and nurse call light are, the nurse should start the interview process. In this situation, the nurse may have to pace the interview according to the client's comfort level. The nurse will also have to select focused questions and get information in a quick manner since the client is acutely ill. Medication may affect the client's ability to think clearly, so again, getting as much information quickly is key here. |
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A nursing diagnosis of Enhanced readiness for spiritual well-being has been formulated for a particular family. Which of the following data clusters would support this diagnosis?
A) The children have attended private school, and the parents are involved minimally in school activities. B) The family visits different congregations, the parents have been reflecting on their own spiritual upbringings, and the children are questioning rituals of their friends and friends’ families. C) The grandparents go to weekly services and have formal interaction with clergy. D) The children attend Sunday school classes, the parents take turns driving and doing errands during this time, and the parents have little interaction with congregational activities |
B
A wellness diagnosis describes human responses to levels of wellness in an individual family or community that has a readiness for enhancement or improvement. The data cluster that describes the questioning, searching, and reflecting would support an attitude of readiness. The other options merely show activities but no real interest in improvement. |
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A nursing student is learning the application of the nursing process to client care. When questioned by the student about the reason for implementing a nursing diagnosis, the nursing professor responds: “The nursing diagnosis statement:
A) “Describes client problems that nurses are licensed to treat.” B) “Helps standardize care for all clients.” C) “Helps other health care professionals understand the plan of care.” D) “Includes the disease the client has during the treatment of care.” |
A
The domain of nursing diagnoses includes only those health states that nurses are educated and licensed to treat. A nursing diagnosis is a judgment made only after data collection. Nursing diagnoses describe a continuum of health states: deviations from health, presence of risk factors, and areas of enhanced personal growth. The nursing diagnosis statement is specific to nursing and nurses and does not include the medical diagnosis. The nursing diagnosis, like the plan of care, is specific to each individual client and the client’s situation. |
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A nurse is taking a health history from a client who states that he has been to numerous physicians and has had a lot of laboratory tests (all of which were abnormal) and exploratory surgery, but no one is able to explain the etiology of his problem. The client also states that he has a PhD in epidemiology and he has a rare form of a neurological disorder. The nurse who utilizes critical thinking will make this statement:
A) "Did you bring your prior tests and results with you, so we don't repeat anything?" B) "Why don't you just tell your physician what you think you have?" C) "Describe what tests you've had and explain the symptoms of this disorder." D) "If you know what you have, what do you want from us?" |
C
In critical thinking, the nurse also differentiates statements of fact, inference, judgment, and opinion. The nurse will have to ascertain the accuracy of information and evaluate the credibility of the information sources. "Why" questions make clients very defensive. Asking a "yes/no" question offers little other information. Asking the client what he wants does not help to find out more information about the client's situation or prior history. |
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During an assessment interview, the nurse understands that the client has decided not to take the physician's advice about an elective surgical procedure. The client shares that this is "just not part of what I have in mind for my life's goals." This would fall into which of Gordon's functional health patterns?
A) Health-perception/health-management pattern B) Cognitive/perceptual pattern C) Value/belief pattern D) Coping/stress-tolerance pattern |
C
The value/belief pattern describes the patterns of values, beliefs (including spiritual), and goals that guide the client's choices or decisions. The client in this situation has decided against a surgical procedure because it doesn't coincide with the client's beliefs and goals. Cognitive perceptual patterns describe sensory-perceptual and cognitive patterns. Coping/stress-tolerance patterns describe the client's general coping pattern and the effectiveness of the patterns in terms of stress tolerance. Health-perception/health-management pattern describes the client's perceived pattern of health and well-being and how health is managed. |
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A client has been admitted to the cardiac intensive care unit following an acute myocardial infarction. The nurse formulates the following nursing diagnosis: Acute pain, related to tissue damage, secondary to infarction, manifested by pallor, client report, and shallow, rapid breathing. Which of the following would be an example of a collaborative intervention?
A) Monitor for changes in the client's condition. B) Administer pain medication. C) Provide a calm, quiet atmosphere in the client's room. D) Educate the client and family regarding treatment and therapies. |
B
Collaboration occurs between the nurse, physician, and other health care professionals to treat the client's problem. In this case, the physician prescribes medications, and the nurse administers thema primarily dependent action that requires physician orders. The other options are nurse mediated, which the nurse can implement independently. |
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The nurse makes the decision to look at alternatives for wound care with a client who has a stasis ulcer that has been treated over the past 2 weeks. The nurse was hopeful to see some improvement by this time. This represents which phase of the nursing process?
A) Assessment B) Implementation C) Evaluation D) Diagnosis |
C
Evaluation is measuring the degree to which goals/outcomes have been achieved and identifying factors that positively or negatively influence goal achievement. Activities of evaluation include judging whether goals/outcomes have been achieved and making decisions about problem status. The client's wound is not healing and the nurse decides to modify the nursing interventions. Diagnosis is problem identification. Implementation is carrying out (or delegating) the planned nursing interventions. Wound care would be the implementation of this particular case. Assessment is collecting and organizing data. |
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A 2-year-old has been admitted to the pediatric unit with a 2-day history of vomiting and diarrhea. Which of the following would be a cue the nurse identifies as being outside the normal standard?
A) The child is not able to stand alone. B) The child cries when parents leave the room. C) The child is able to hold finger foods. D) The child's weight is 25 lb. |
A
A developmental delay that should cue the nurse to a probable problem would be that this 2-year-old is not able to stand by himself. Most children are walking between 12 months and 18 months. The other data are considered normal behavior for a 2-year-old. |
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Wanting to know more about the client's pain experience, the nurse continues to explore different questioning techniques. Which of the following is the best example of an open-ended question for this situation?
A) "How has the pain impacted your life?" B) "Is your pain worse at night?" C) "What brought you to the clinic?" D) "You're feeling down about having pain, aren't you?" |
A
An open-ended question would be beneficial to explore more about the client's experience and should be asked with a "how" or "what." Closed questions can be answered with one or two words. A neutral question is a question that the client can answer without direction or pressure from the nurse. A neutral question is open-ended and is used in nondirective interviews, which is what would be used if the nurse didn't understand the reason for the client's visit. A leading question is usually closed and directs the client's answer (the nurse stating how the client is feeling, for example). |
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The nurse is taking information for the client's database. The client is not very talkative; is pale, diaphoretic, and restless in the bed; and tells the nurse to just "leave me alone." Which of the following is subjective data?
A) Not talkative B) Pale and diaphoretic C) Restlessness D) "Leave me alone" |
D
Subjective data can be described or verified only by that person and are apparent only to the person affected. Subjective data include the client's sensations, feelings, beliefs, attitudes, and perceptions of personal health status and life situations. Restlessness, not being talkative, and paleness with diaphoresis are what the nurse is observing. |
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A client just had a baby following a long labor and difficult delivery. Which of the following nursing diagnoses is formulated correctly?
A) Constipation, due to tissue trauma, manifested by no bowel movement for 2 days B) Ineffective breast-feeding, related to lack of motivation, secondary to exhaustion C) Risk for infection, because of new incision, related to episiotomy D) Altered urinary elimination, secondary to childbirth |
B
The problem statement is listed first (NANDA label), followed by the etiologyfactors that contribute to or are the cause of the client’s response. The two parts are joined by the words related to, implying a relationship between the two. Adding a second part to the etiology statement makes it more descriptive and useful. Due to and because of are not appropriate wording of the NANDA statement. |
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A client has had a nonhealing wound for a period of time. The home health nurse decides to implement a variety of wound care products to see if any of them work. Each day, the nurse switches to a different brand or product. In this situation, the nurse is utilizing which method of problem solving?
A) Research process B) Trial and error C) Scientific method D) Intuition |
B
Trial and error is solving problems by utilizing a number of approaches. Trial-and-error methods can be dangerous in nursing because the client might suffer harm if an approach is inappropriate. In this case, the client may not suffer harm, but there will be no way to know if one product used is effective since the nurse is changing them on a daily basis. Intuition is the learning of things without conscious use of reasoningalso known as the sixth sense, hunch, or instinct. Scientific method and research process are both formalized, systematic, and logical approaches to solving problems. |
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The nurse is collecting information from a client's family. The client is confused and not able to contribute to the conversation. The spouse states, "This is not his normal behavior." The nurse documents this as which of the following?
A) Secondary subjective data B) Objective data C) Inference D) Subjective data |
B
Information supplied by family members, significant others, or other health professionals is considered subjective if it is not based on fact. Since this information is factual, in that the spouse is able to provide the nurse with information about the client's routine behavior and patterns, that is objective data. Inference is making a judgment. |
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A client is coming in to the clinic for the first time. In order for the nurse to allow the client the most comfort during the interview, the nurse should:
A) Stand at the counter to take notes during the interview. B) Stand at the side of the client's chair. C) Sit behind a desk. D) Sit next to the client, a few feet apart. |
D
A seating arrangement in which the client and nurse are seated in chairs, a few feet apart, at right angles to each other and with no table between creates a less formal atmosphere, with the nurse and client feeling on equal terms. This would allow for more comfort and relaxation during the interview phase. Sitting behind a desk creates a formal arrangement that suggests a business meeting between a superior and subordinate. Standing and looking down at a client who is in a chair risks intimidating the client. |
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A client is diagnosed with pneumonia and has been hospitalized for several days. A priority nursing diagnosis for this client is which of the following?
A) Altered oral mucous membranes, related to dry mouth B) Knowledge deficit, related to medication regimen C) Ineffective airway clearance, related to increased secretions D) Activity intolerance, related to oxygen supply imbalance |
C
Prioritizing care must begin with the basic needs, in this case, the airway. All other options are appropriate but do not match the need for a clear airway. The nurse must attend to this first, before acting on other needs of the client. |
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When learning how to implement the nursing process into a plan of care for a client, the student nurse realizes that part of the purpose of the nursing process is to:
A) Make sure that standardized care is available to clients. B) Deliver care to a client in an organized way. C) Identify client needs and deliver care to meet those needs. D) Implement a plan that is close to the medical model. |
C
The purpose of the nursing process is to identify a client's health status and actual or potential health care problems or needs, to establish plans to meet the identified needs, and to deliver specific nursing interventions to meet those needs. Delivery or organized care is not part of the nursing process, though each phase is interrelated. The nursing process is not part of the medical model as nurses treat the client's response to the disease or problem. The nursing process is individualized for each client's care plan. It is not about standardizing care. |
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A nurse has just been informed that a new admission is coming to the unit. According to the 2005 JCAHO requirements, how long does the nurse have to complete a physical assessment and have a documented history and physical on the chart?
A) 12 hours B) 1 hour C) 24 hours D) 48 hours |
C
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires that each client have an initial assessment consisting of a history and physical performed and documented within 24 hours of admission as an inpatient. |
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A client comes to the clinic seeking information and education regarding healthy lifestyles and eating habits. The most appropriate diagnosis for this client is which of the following?
A) Wellness diagnosis B) Actual diagnosis C) Syndrome diagnosis D) Risk nursing diagnosis |
A
A wellness diagnosis describes the human response to levels of wellness in an individual. This client is seeking information about behavior changes and improvement to assist him in making choices and changes to enhance his life. A risk diagnosis is a clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene. A syndrome diagnosis is associated with a cluster of other diagnoses. An actual diagnosis is a client problem that is present at the time of the nursing assessment. |
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A client comes into the emergency department (ED) with a productive cough, audible coarse crackles, elevated temperature of 102.3°F, chills, and body aches. The nurse identifies the problem as respiratory compromise. The nurse is using which of the following?
A) Critical analysis B) Socratic questioning C) Deductive reasoning D) Inductive reasoning |
C
Deductive reasoning is reasoning from the general to the specific. The nurse starts with a framework and makes descriptive interpretations of the client's condition in relation to the framework. Productive cough, crackles, fever, and chills all point to problems with respiratory status. Inductive reasoning would be making a generalization from a set of facts or observation. In this case, the nurse using inductive reasoning could presume that the client has bronchitis or a bacterial respiratory infection. Socratic questioning is a technique of critical analysis, looking beneath the surface and asking questions to come to a conclusion about the situation. |
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The student nurse understands that clustering data comes with experience and recognizing cues. The best way for this student to recognize patterns or cues in the data is to:
A) Take assessment notes and utilize information from textbooks for comparison. B) Work with seasoned and experienced nurses and learn from them. C) Depend on knowledge gained from peers’ experiences. D) Know that this will take time, and experience is the best teacher. |
A
The novice nurse must take careful assessment notes, search data for abnormal cues, and use textbook resources for comparing the client’s cues with the defining characteristics and etiologic factors of the accepted nursing diagnoses. Learning from peers and seasoned nurses is helpful, but does not take the place of didactic information in textbooks. Experience teaches much information, but it never takes the place of concrete, scientific theory from a textbook. |
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The nurse is taking a health history from a client who has complications from chronic asthma. Which of the following is an example of an open-ended question?
A) "Can you describe your coughing pattern?" B) "How would you describe your sleep pattern?" C) "What medications are you on?" D) "Is there anything that makes your breathing worse?" |
B
Open-ended questions invite clients to discover and explore, elaborate, clarify, or illustrate their thoughts or feelings. They specify only the broad topic to be discussed. Open-ended questions invite long answerslonger than one or two words. Closed questions can be answered with short, factual, and specific information. |
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Nurses must use critical thinking in their day-to-day practice, especially in circumstances surrounding client care and wise use of resources. In which of the following situations would critical thinking be most beneficial?
A) Teaching new parents car seat safety B) Assisting an orthopedic client with the proper use of crutches C) Administering IV push meds to critically ill clients D) Educating a home health client about treatment options |
D
Nurses who utilize good critical-thinking skills are able to think and act in areas where there are neither clear answers nor standard procedures. Treatment options, especially for the home health client, can be extensive. There are many points to consider (good and bad), and choosing between treatment options can cause conflict among family members. The nurse in this case must use creativity, analysis based on science, and problem-solving skillsall of which contribute to critical-thinking skills. Administering IV meds (even to critically ill clients), teaching correct use of crutches, and teaching new parents about car seat safety do not require as much reasoning. There are standard procedures to follow and, most of the time, clear answers about the rationale. |
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The nurse makes this entry in the client's chart: "Client avoids eye contact and gives only vague, nonspecific answers to direct questioning by the professional staff. However, is quite animated (laughs aloud, smiles, uses hand gestures) in conversation with spouse." This is an example of which method of data collection?
A) Examining B) Observing C) Listening D) Interviewing |
B
Observation is a conscious, deliberate skill that is developed through effort and with an organized approach. Observation occurs whenever the nurse is in contact with the client or support persons. Examining is the major method used in the physical health assessment. Interviewing is used mainly while taking the nursing health history. Listening is part of observing. |
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A client has been having pain without any clear pathology for cause. The x-rays are normal, the client did not have an injury or fall, and there has been no recent trauma. The most appropriately written nursing diagnosis for this client would be which of the following?
A) Pain related to unknown etiology B) Pain manifested by client’s report C) Pain due to unknown factors D) Pain caused by psychosomatic condition |
A
The second part of the nursing diagnosis statement is the etiology (E)the factors contributing to or probable causes and should be joined to the first part, the problem (P), by the words related to rather than due to. The phrase related to implies a relationship between the problem and the cause. In this situation, the cause is unknown, but the problem is evident. Making an assumption that the cause is psychosomatic is not within the nurse’s scope of practice. The third part of the nursing diagnosis statement is the manifested by (S) portion, which includes the signs and symptoms. |
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A nurse is completing a plan of care for a client. The statement "client will be able to walk 10 feet, twice a day without shortness of breath" is which part of the nursing process (in comparison to the decision-making process)?
A) Assess B) Plan C) Evaluate D) Diagnose |
B
The planning portion of the nursing process involves setting criteria (walking 10 feet twice a day), weighting the criteria, and seeking/examining alternatives when compared to the decision-making process. Assessment is the same as identifying the purpose. Diagnosing is putting a label on the problem. Evaluating is reviewing the outcome. |
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A seasoned nurse works in a busy ICU unit. When a particularly complex client is admitted, the nurse uses past experiences and knowledge gained from those situations to help care for this client. The nurse is fully aware that in the future, an even more complex case may be in the workload. This nurse is practicing which of the attributes of critical thinking?
A) Context B) Reflection C) Dialogue D) Time |
D
The attribute of time emphasizes the value of using past learning in current situations that then guide future actions. Reflection involves being able to determine what data are relevant and to make connections between that data and the decisions reached. Context is an essential consideration in nursing since care must always be individualized, taking knowledge and applying it to real people. |
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A client who has just been diagnosed with pancreatic cancer is quite upset and verbal. The nurse has formulated the following diagnosis: Anxiety, related to unfamiliarity of disease process, manifested by restlessness and tachycardia. The etiology of this diagnosis is which of the following?
A) Tachycardia B) Unfamiliarity of disease process C) Anxiety D) Restlessness |
B
The etiology is the underlying cause and a contributing factor of the client's response. In this case, the uncertainty of the diagnosis, fear of the unknown, and response to the diagnosis cause the client to become anxious and upset. Anxiety is the NANDA labelthe problem identified. Restlessness and tachycardia are the defining characteristics which the client exhibits. |
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A nurse has worked in the trauma critical care area for several years. Which of the following noises may become indiscriminate for this particular nurse?
A) Co-workers discussing their clients' conditions B) Moaning of a client in pain C) A client with audible breathing D) Whirring of ventilators |
D
Nurses often need to focus on specific data in order not to be overwhelmed by a multitude of data. Observing involves discriminating data in a meaningful manner (i.e., noticing things that may indicate cause for concern or action on the nurse's part). Listening to a client's breathing helps the nurse become attentive to changes in breathing patterns. A client's moans of pain should never become easy to listen to. Listening to co-workers discuss other clients on the unit is helpful in case the nurse has to attend to any one of them. The noises of machines and other equipment noisesexcept alarmswould be easy to ignore as these are the usual, normal sounds of the unit. |
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A nursing student is meeting an assigned client for the first time. In order to begin the establishment of rapport, the best statement by the student is:
A) "Good morning, is there anything you need right now?" B) "Hi. If you need anything, either your nurse or I will get it for you." C) "Hello, I'm your nursing student and I'll be helping to take care of you today." D) "You're lucky, you have students and nurses taking care of you today." |
C
Establishing rapport is a process of creating goodwill and trust and usually begins with a greeting and self-introduction, accompanied by nonverbal gestures such as a smile, a handshake, and a friendly manner. Telling a hospitalized client he or she is lucky is probably not the best therapeutic comment. Making introductions, especially offering the use of name, is especially good in establishing rapport. |
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A nurse has delegated to a nurse's aide to obtain vital signs for a newly admitted client. The aide reports the following: temperature = 99.3(F), respirations = 26, pulse = 98 bpm, and blood pressure = 200/146. To validate the data, the best action by the nurse is:
A) Report the findings to the charge nurse. B) Continue with the physical assessment as soon as possible. C) Call the physician. D) Retake the vital signs. |
D
Guidelines for validating assessment data that are out of normal range include repeating the measurements, using another piece of equipment as needed to confirm abnormalities, or asking someone else to collect the same data. In this situation, the nurse needs to be sure that the vital signs are accurate. Calling the physician and reporting the findings to the charge nurse before they have been validated would be premature. The physical assessment should be done as soon as possible anyway, but not until after the vital signs have been validated. |
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An infant has been admitted to the pediatric unit. The parents are quite worried and upset, and the grandmother is also present. In this situation, what would be the best source of data?
A) Grandmother, since the parents are upset B) Admitting physician C) Medical record from the child's birth D) Parents |
D
The best source of data is usually the client, unless the client is too ill, young, or confused to communicate clearly. Even though the parents are upset, they would be able to provide the nurse with the most accurate, current information regarding the baby (diet, schedule, symptoms, etc.). The grandmother can support the parents during this time and may be able to offer some helpful information. The baby's birth record and admitting physician will also be able to provide necessary information, but not to the extent as the parents. |
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A client has just been admitted, is complaining of shortness of breath, has no pallor, no cyanosis, and no accessory muscle use with respirations. The client's respiratory rate is 16 breaths per minute. The nurse is performing the assessment and continues to ask herself how the client's report and the physical findings conflict. This nurse is using which universal standard of critical thinking?
A) Clarity B) Significance C) Accuracy D) Logicalness |
D
Logicalness would ask if the report follows from the evidence. In this case, it does not. However, the nurse is still questioning which shows she is engaged in critically thinking through the situation. Clarity provides examples. Accuracy is asking if something is true. Significance is prioritizing the facts. |
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The nurse has completed the initial assessment of a client and has analyzed and clustered the data. The nurse's next step in the diagnostic process is to:
A) Formulate a diagnosis. B) Verify the data. C) Identify the client's problem, health risks, and strengths. D) Research collaborative and nursing-related interventions. |
C
The three phases of the diagnostic process are data analysis; identification of the client's health problems, health risks, and strengths; and formulation of diagnostic statements. Verifying the data should be done at the end of the assessment/interview phase. Researching collaborative and nursing-related interventions comes after setting goals or outcomes and is not part of the diagnostic process, rather part of the implementation phase. |
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An experienced nurse has just walked into the room of a client to whom the nurse has been assigned for the shift. Which of the following might be a significant cue?
A) The client’s skin is pale and mottled. B) The client’s eyes are closed. C) The client’s spouse is asleep in the chair next to the bed. D) The TV is on and the volume is turned up. |
A
Nurses draw on knowledge and experience to compare client data to standards and norms and to identify significant and relevant cues. A cue is considered significant if it points to changes in the client’s health status or pattern, varies from norms of the client population, or indicates a developmental delay. Pale, mottled skin could indicate coldness, a problem with circulation, or even death. Since the client’s eyes are closed and the spouse is asleep, the experienced nurse may immediately consider that there is something very wrong with this picture. |
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The nurse is doing teaching regarding medication administration for a client who is being discharged. Which of the following instructions should be rewritten for this client?
A) Lasix, 20 mg by mouth 8 AM and 2 PM B) Lasix, 20 mg, po twice daily C) Lasix, 20 mg, po bid D) Lasix, 20 mg by mouth, twice a day |
C
If the discharge plan is given directly to the client and family, it is imperative that instructions be written in terms that can be readily understood. For example, medications, treatments, and activities should be written in layman's terms, and use of medical abbreviations should be avoided. Twice a day should be written out, not abbreviated as bid. |
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A student nurse is working on a care plan for an assigned client. One of the interventions the student nurse would like to include in the plan is to assist the client with ambulation. Which of the following is the best way to state this plan?
A) Assist client with ambulation. B) Client will ambulate in hallway twice daily. C) Ambulate with client, using a gait belt, twice daily for 15 minutes. D) Make sure client understands the rationale for using the gait belt. |
C
A written intervention should include a verb, conditions, and modifiers, plus a time element. Identifying what to do (ambulate), how to do it (with a gait belt), and how long (twice daily for 15 minutes) is the most precise statement. "Client will ambulate in the hallway" is a goal statement, not an intervention. |
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After completing the clinical and documenting in the progress notes, the nursing student discovered he had written in the wrong chart. The correct action is to:
A) Use white-out over the mistake. B) Put an "X" through the entire page, identify it as an "error," initial, and move on to the correct chart. C) Draw a single line through the documentation, write "mistaken entry" next to the original entry, and initial it. D) Take a wide permanent marker and blacken out all the documentation. |
C
When a mistake is recorded, a line should be drawn through it and the words "mistaken entry" written above or next to the original entry, then initial or signaturewhichever is agency policy. The original entry must remain visible. Erasure, blotting out, or correction fluid should not be used. |
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A nursing unit has had a large number of negative client responses about various aspects of their care in the previous quarter. The quality assurance officer is evaluating this unit, paying particular attention to which of the components of care?
A) Structure B) Process C) Outcome D) Competency |
Process evaluation focuses on how the care was given. Is the care relevant to the clients' needs? Is it appropriate, complete, and timely? Process standards focus on the manner in which the nurse uses the nursing process. Competency is not one of the components of quality assurance evaluation. Structure evaluation focuses on the setting in which the care is given. Outcome evaluation focuses on demonstrable changes in the client's health status as a result of nursing care.
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A nurse is working with a client who has a diagnosis of Impaired skin integrity, related to immobility, secondary to neurologic dysfunction. Of the following listed, which would be considered an observation intervention?
A) Provide ongoing assessment for skin breakdown every shift. B) Turn and reposition client every 2 hours. C) Apply lotion to dry skin twice daily. D) Cushion bony prominences with soft foam while in bed. |
A
Observations include assessments made to determine whether a complication is developing as well as observations of the client's responses to nursing and other therapies. Assessment for skin breakdown would fall under this category. Prevention interventions prescribe the care needed to avoid complications or reduce risk factors. Turning and repositioning as well as cushioning bony prominences would help prevent any further skin breakdown. Application of lotion or other treatments to areas of skin impairment would be considered a treatment intervention. |
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A nursing unit has been short staffed for the past month with a heavy client load and high acuity. The nurses on this unit have been working extra as well as double shifts and often do not have time to make sure that properly working equipment is cleaned, returned, and stored in the appropriate areas. This unit should be evaluated at which level?
A) Structure B) Process C) Outcome D) Management |
A
Structure evaluation focuses on the setting in which care is given. Structural standards describe desirable environmental and organizational characteristics that influence care, such as equipment and staffing. Process evaluation focuses on how the care was given. Outcome evaluation focuses on demonstrable changes in the client's health status as a result of nursing care. Management is not one of the three components of quality assurance evaluation. |
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A nurse has taken a position with an insurance company to review clients' records and the care they received while they were inpatient status. Part of the job description requires the nurse to make sure the client (and insurance company) were billed for services and treatment/therapies rendered and that there were no errors in billing. This type of audit is which of the following?
A) Concurrent B) Nursing audit C) Retrospective D) Peer review |
C
A retrospective audit is the evaluation of a client's record after discharge from an agency. The word retrospective means "relating to the past." If the nurse is reviewing records after the client has been discharged, the information being examined is in the past. Concurrent audit is the evaluation of a client's health care while the client is still receiving the care from an agency. A nursing audit is a type of peer review, in which the audit focuses on evaluating nursing care through the review of records. |
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The nurse responds to a client's call light. When entering the room, the nurse sees that the client is lying on the floor, with the bed linens around the legs. The most correctly written chart entry is:
A) Client became tangled in the bed linens, then called for assistance after falling out of bed. B) Recorder responded to client's call light, upon entering the room, found client on floor. C) Client fell out of bed, but did push the call button for assistance. D) Client found on floor, appeared to have fallen out of bed as a result of getting tangled in bed linens. |
B
Accurate notations consist of facts or observations rather than opinions or interpretations. The client was found on the floor, and the call light was activated. Those are the only things known until the nurse learns further information from questioning the client. It should never be assumed that the client fell out of bed, became tangled in bedding, or anything else. |
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A client has been in the hospital for several days following a CVA (cerebrovascular accident). One of the diagnoses formulated for this client is Risk for aspiration, related to neuromuscular dysfunction. Of the following interventions, which includes a rationale?
A) Provide frequent assessment for presence of obstructive material in mouth and throat. B) Clear secretions from oral/nasal passageways as needed. C) Have suction equipment available at all times. D) Keep client in low-Fowler's position to prevent reflux. |
D
A rationale is the scientific principle given as the reason for selecting a particular nursing intervention. It helps explain "why" an intervention would be implemented. Keeping the client in a position with the head elevated 30 to 45 degrees helps prevent the risk of reflux (food/liquids returning up through the esophagus after having been swallowed). None of the other options state "why" they are being performed. |
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A nurse moves to a new city and begins work in a hospital that utilizes the NOC classification taxonomy. The nurse understands that this system can be compared to which of the following?
A) Nursing diagnosis statement B) Planning portion of the care plan C) Goal statement of the traditional care plan D) Implementation phase of the care plan |
C
The Nursing Outcomes Classification (NOC) describes client outcomes that respond to nursing interventions. The nursing diagnosis statement must follow the NANDA format. Goal setting is part of the planning, but the NOC outcome is narrower in use than general planning. Implementation is compared to the Nursing Interventions Classification (NIC) taxonomy. |
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A nurse is caring for a client in a trauma ICU in the middle of the night. The client is having difficulty maintaining blood pressure, and the nurse administers a routinely used medication for this problem. This is an example of the nurse implementing which of the following?
A) A STAT order B) A standing order C) A prn order D) A one-time order |
B
Standing orders are a written document about policies, rules, regulations, or orders regarding client care. Standing orders give the nurses authority to carry out specific actions under certain circumstances, often when a physician is not immediately available. A STAT order is one that must be carried out immediately. A one-time order is for an action to be done only once; prn is pro re nataLatin for "as needed." |
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The nurse administered analgesic medications to an assigned client via central line. This information should be documented in which section if using PIE charting?
A) Plan B) Evaluation C) Progress notes D) Intervention |
D
The interventions employed to manage the problem are labeled "I" and numbered according to the problem. The problem statement is labeled "P" and referred to by number. The "E" is evaluation of the effectiveness of the intervention and is also labeled and numbered according to the problem. Progress notes are not part of the identified labels of PIE charting. |
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One of the interventions for a client with a nursing diagnosis of Impaired swallowing is to position the client upright in a chair (60 to 90 degrees) during feeding times. The modifier in this intervention is which of the following?
A) 60 to 90 degrees during feeding times B) Upright in a chair C) Impaired swallowing D) Position in chair |
A
Conditions or modifiers may be added to the verb to explain the circumstances under which the behavior is to be performed. They explain what, where, when, or how. In this case, defining "upright" as 60 to 90 degrees and "during feeding times" gives when this should be done. The words "positioning" and "upright" are not descriptive enough for modifiers. Impaired swallowing is the NANDA label. |
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A client has specific cultural needs in regard to the plan of care. This information would be found in which of the following?
A) Progress notes B) Database C) Problem list D) Plan of care |
C
The problem list is derived from the database and is usually kept at the front of the chart. The problem list serves as an index to the numbered entries in the progress notes. All caregivers contribute to the problem list, which includes the client's physiologic, psychologic, social, cultural, spiritual, developmental, and environmental needs. The database includes information about the client when admitted to the facility. The plan of care is made with reference to the active problems. Progress notes are chart entries made by all health professionals involved in a client's care. |
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The client states: "I really don't want anyone to visit me who has not been OK'd with me first." If utilizing SOAP format, this statement would be documented under which category?
A) Subjective data B) Assessment C) Objective data D) Planning |
A
Subjective data consist of information obtained from what the client says. When possible, the nurse quotes the client's words; otherwise, they are summarized. Objective data consist of information that is measured or observed. Assessment is the interpretation or conclusion drawn about the subjective and objective data. This is the area where the problems are documented initially. Then the client's condition and level of progress are subsequently described. Planning is the care designed to resolve the problem. |
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When implementing a care plan, the nurse involves a client who is ready for discharge in the planning. One of the goals is that the client will have improved mobility. Which of the following might be an appropriate desired outcome statement for this goal?
A) Client will have freer movement in daily activities. B) Client will ambulate freely in house. C) Client will not fall. D) Client will ambulate without a walker by 6 weeks. |
D
Desired outcomes are the more specific, observable criteria used to evaluate whether the goals have been met. Ambulating without a walker by a certain date is specific as well as measurable. "Ambulate freely" does not give a time frame, therefore it is not as specific. Goals stated as "will not fall" or "have freer movement in daily activities" are too vague, have no time limit, and do not give the nurse a good set of criteria to evaluate the goal. |
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A nurse makes an entry in a client's chart that includes documentation about the routine care, assessment findings, and client problems. This documentation is arranged in a chronological order, from the time the nurse started the shift until the nurse entered the documentation in the client's record. This is an example of which of the following?
A) Plan of care B) Narrative charting C) Problem-oriented recording D) Source-oriented recording |
B
Narrative charting is a traditional part of the source-oriented record. It consists of written notes that include routine care, normal findings, and client problems. There is no right or wrong order to the information, although chronological order is frequently used. Problem-oriented recording is arranging the data according to the problem the client has. Source-oriented recording is arranged in separate sections for each department that contributes to the client's care. Plan of care is part of the problem-oriented medical record. |
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The client is brought to the emergency department by the police. There are numerous large areas of bruising around the client's throat and upper arms, the client's lip is cut, and the client's clothes are ripped. The documentation that is most correctly written for this situation is:
A) Client brought to ED by police. Bruising to throat and upper arms, measuring ____ to _____ cm. Clothes ripped. B) Client had areas of bruising on throat and upper arms-as if someone had choked the client-clothing ripped. C) Police brought client to the ED after getting beat up. Clothes ripped, bruising to throat and upper arms. Lip cut. D) Client brought to the ED, victim of some type of abuse, in the custody of the police. |
A
Notations on records must be accurate and correct. Accurate notations consist of facts or observations rather than opinions or interpretations. Data should be specific. In this case the bruises would be measured and measurements recorded, or pictures could be taken according to some departments' policies. Assuming that the client is a victim of abuse, or that the client had been beaten or choked is opinion and interpretation, not fact and observation. |
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A client is on a regular surgical unit following a knee repair. When caring for the client, the nurse performs independent as well as dependent interventions. Which of the following is an example of a dependent intervention?
A) Repositioning the client every 2 hours B) Assisting the client with transfers to the bathroom C) Administering medications for pain D) Providing ongoing physical assessment, especially of the incisional sites |
C
Dependent interventions are those activities carried out under the physician's orders or supervision or according to specified routines. The nurse is responsible for assessing the need for and administering medications, but the physician prescribes them. All other options listed are examples of independent interventionsthose activities that the nurse is licensed to initiate on the basis of knowledge and skills. |
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A nursing unit's records of client care have been reviewed for accuracy in documentation. This type of review is which of the following?
A) Peer review B) Nursing audit C) Individual audit D) Concurrent audit |
B
An audit is an examination or review of records. A nursing audit is a type of peer review that focuses on evaluating nursing care through the review of records. The success of these audits depends on accurate documentation. Peer review is a type of evaluation where nurses functioning in the same capacity perform the audit. Peer review is based on preestablished standards or criteria. An individual audit focuses on the performance of an individual nurse. Concurrent audits are reviews of a client's health care and occur while the client is still receiving the care. |
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The written goal statement in a client's care plan is: Client will have clear lung sounds bilaterally within 3 days. One of the interventions to meet this goal is that the nurse will teach the client to cough and deep breathe and have the client do this several times every 2 hours. At the end of the third day, the client's lungs are indeed clear. In order to relate the intervention to the outcome, the nurse should:
A) Ask how many times per day the client practiced the coughing and deep breathing exercises. B) Document the assessment findings to show the effectiveness of the intervention. C) Tell the client that the lungs are clear. D) Write this evaluation statement: Goal met, lung sounds clear by third day. |
A
Part of the evaluating process is determining whether the nursing activities had any relation to the outcomes. Did the lungs clear because the client actually did the coughing and deep breathing? In order to know for sure, the nurse must collect more data and not assume that this particular nursing intervention had any relation to the outcome. Documenting does not show effectiveness of the intervention, and neither does writing an evaluation statement. The nurse needs to ask if the client even did any coughing or deep breathing. |
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A teenage client has been having problems with peer support, school performance, and parental expectations, all of which have led to an eating disorder. After gathering this assessment data, the nurse formulate the diagnosis Activity Intolerance related to weakness. After evaluating this information, the nurse should realize which of the following?
A) The diagnosis is directly related to the data presented. B) The nursing diagnosis is not relevant to the data. C) The data are not sufficient enough to support this diagnosis. D) The data collected would support the diagnosis. |
C
An incomplete database influences all steps of the nursing process and care plan. The nurse must complete the assessment before formulating a diagnosis about weakness and fatigue. Perhaps this diagnosis is appropriate for this client, but there are not enough data presented to know that for sure. Once data are complete, the diagnosis and information need to be relevant to each other. |
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A client is struggling to learn how to care for a new colostomy. The nurse is following the written care plan and has selected to provide written information along with a demonstration on how to accurately measure the stoma for attaching the appliance. Upon entering the room, the client is crying along with the client's spouse. The nurse decides to sit with both of them, offering presence and listening to their fears instead of the planned education. This is an example of which of the following?
A) Implementing nursing intervention B) Reassessing the client C) Supervising delegated care D) Determining the nurse's need for assistance |
B
Just before implementing an intervention, the nurse must reassess the client to make sure the intervention is still needed or to discover if there are new data that indicate a need to change the priorities of care. In this case, the client and the spouse are not in a good frame of mind to listen to or retain any kind of teaching/learning experience. Instead, the nurse reassesses the situation and implements a more appropriate intervention. In this situation, the nurse does not need assistance, nor is this a situation where the nurse must supervise care that has been delegated. |
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The home health nurse must devise a way to administer IV antibiotics to a client who insists on being outside during the infusion. Using creativity and critical thinking, the nurse is able to meet the client's requests. This is an example of which of the following?
A) Creativity B) Technical skill C) Cognitive skill D) Interpersonal skill |
C
Cognitive skills include problem solving, decision making, critical thinking, and creativity. Finding a unique way to provide the treatment while keeping the client's wishes in mind is an example of the nurse using cognitive abilities. Technical skills are "hands-on" skills such as manipulating equipment, giving injections, bandaging, moving, lifting, and repositioning clients. Though this task in the scenario involves some technical skill, the more apparent one is that of a cognitive level. Interpersonal skills are all of the activities, verbal and nonverbal, people use when interacting directly with one another. Creativity is part of cognitive skill. |
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A nurse is helping a client with planning following a surgery in which the client had a permanent colostomy placed. Which of the following would be considered a short-term goal for this client? Client will:
A) Maintain a positive self-esteem. B) Have a formed bowel movement every 2 days. C) Identify food sources that are problematic for the situation. D) Be able to state signs and symptoms of skin breakdown. |
D
Initially, a client with a new colostomy must be aware of the signs and symptoms of skin breakdown and have a good knowledge base about basic skin care regimen. This should be accomplished before the client leaves the hospital in order to prevent problems at home. Normal bowel elimination patterns may not be present for some time, depending on the client's diet and activity level. This would be a long-term goal. Knowledge about what particular foods may cause problems for this client would be information the client gathers as time goes on. What perhaps was not a problem prior to the surgery may now cause gas, bloating, diarrhea, or constipation. Overcoming body image changes for this client may take some time and this would be considered a long-term goal. |
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A child is admitted to the hospital for complications from diabetes. Which of the following nursing diagnoses will the nurse focus on as priority?
A) Risk for infection, related to circulatory changes, secondary to high blood glucose levels B) Altered nutrition, less than body requirements, related to inability to maintain glucose level C) Fear, related to unfamiliar surroundings D) Ineffective management of therapeutic regimen, related to complexity |
B
Prioritizing is the process of establishing sequencing for addressing nursing interventions. The nurse in this case must decide which diagnosis requires attention first. Physiologic needs are basic to life and receive higher priority than the need for security and education. Identifying a potential problem, but one that is not present, would take the lowest priority. |
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A hospital is implementing the use of NIC (Nursing Interventions Classification) taxonomy. This taxonomy will:
A) Help the nurse with documentation of the care plan. B) Match nursing diagnoses to exact interventions. C) Still require that the nurse use sound judgment and knowledge of the client. D) Help the nurse choose activities that are individualized to the client. |
C
The NIC taxonomy, like NOC, is similar to NANDA diagnosesbroadly stated interventions that are standardized in language and generalized in nature. Each nursing diagnosis contains suggestions for several interventions under the NIC taxonomy, and nurses must select the appropriate interventions based on their judgment and knowledge of the client. The NIC taxonomy may or may not help with documentation. Although it would utilize standard language for all nurses and offer suggestions of interventions for each diagnosis, finding the most appropriate interventions still requires individualization for each client. This taxonomy is general and standardized and must be tailored to fit the needs, outcomes, and goals of the individual client. |
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After classroom discussion regarding confidentiality policies and laws protecting client records, a student asks why it's OK for them to review and have access to client records in the clinical area. The nurse educator responds correctly by stating that:
A) "Records are used in educational settings and for learning purposes, but the student is bound to hold all information in strict confidence." B) "Most students review so many records and charts that they could not possibly remember details from any one of them." C) "As long as the clinical instructor is in the area, accessing client records is part of the education process." D) "Confidentiality and privacy laws don't apply to students." |
A
For purposes of education and research, most agencies allow students and graduate health professionals access to client records. The student or graduate is bound by a strict ethical code and legal responsibility to hold all information in confidence. It is the responsibility of the student or health professional to protect the client's privacy by not using a name or any statements in the notations that would identify the client. |
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A client with beginning stages of Alzheimer's disease is being admitted to an assisted living facility. The nurse is helping the client and family with the adjustment process and planning long- and short-term goals for the client as well as the family. An appropriate, realistic short-term goal for this client would be which of the following?
A) Client will maintain a normal weight. B) Client will be oriented to the surroundings. C) Client will not wander out of facility. D) Client will be able to verbalize feelings of anger, fear, and trust, when appropriate. |
B
This type of client should be oriented to his new surroundings within a few days. The client should know which room is his, where the meals are served, where the bathroom is, and so on. All other options listed would be either unrealistic (no wandering, and verbalizing feelings are probably not within the realm of possibilities) or long-term goals (maintaining a normal weight would be an ongoing, long-term goal). |
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A client with terminal cancer has this nursing diagnosis: Pain related to neuromuscular involvement of disease process. The goal statement is as follows: Client will be free of pain within 48 hours. As an intervention, the nurse will administer narcotic analgesics and titrate to an appropriate level. What is the flaw in this plan?
A) The interventions are dependent of nursing. B) The goal is unrealistic. C) The goal statement is written inaccurately. D) The interventions are not clear enough. |
B
When a care plan needs to be modified, discontinued, or changed in some manner, several decisions need to be made. If the nursing diagnosis is accurate, as it is in this case, the nurse should check to see if the goals are attainable and realisticthe flaw in this plan. A client with terminal cancer is not going to be pain-free, regardless of the amount of medication delivered. To think otherwise is inappropriate. The goal statement is written accurately. Dependent interventions would be appropriate, and in this case they are clear. |
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A client is admitted for complications following a routine diagnostic procedure of the colon. The type of care plan that will most likely be implemented for this client is which of the following?
A) Informal nursing care plan B) Individualized care plan C) Standardized care plan D) Formal nursing care plan |
B
An individualized care plan is tailored to meet the unique needs of a specific clientneeds that are not addressed by the standardized care plan. In this situation, the client had complications following a relatively routine proceduresomething that is unplanned and a rare occurrence and must fit with the needs of the client. An informal nursing care plan is a strategy for action that exists in the nurse's mind. A formal nursing care plan is a written or computerized guide that organizes information about the client's care. A standardized care plan is a formal plan that specifies the nursing care for groups of clients with common needs. |
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A hospital is not able to be reimbursed for care a particular client received while in the emergency department. The client came in with chest pain, which was later diagnosed as gastric reflux. A problem in documentation that may have caused the lack of reimbursement would be which of the following?
A) A code cart opened and the client was charged for medications the client did not use. B) The client was charged for an ECG. C) The physician made a diagnostic mistake. D) The client's record contained an incorrect DRG. |
D
Documentation helps a facility receive reimbursement from the federal government. The client's clinical record must contain the correct diagnosis-related group (DRG) codes and reveal that the appropriate care has been given. Codable diagnoses, such as DRGs, are supported by accurate, thorough recording by nurses. |
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A client has neurologic deficits that are causing tremors, unsteadiness, and weakness. An appropriate diagnosis of Risk for Falls related to unsteady gait, secondary to neurologic dysfunction has been formulated. A goal for this client is not to sustain any injuries for the next month. The client however, has fallen several times. In this situation, the nurse should do which of the following?
A) Discard the nursing plan and start over from the assessment phase. B) Modify the whole nursing plan. C) Review the data and make sure that the diagnosis is relevant. D) Investigate whether the best nursing interventions were selected. |
D
Even if all sections of the care plan appear to be satisfactory, the manner in which the plan was implemented may have interfered with goal achievement. The nurse needs to check and see if the interventions were appropriate for the client. If the interventions selected did not help the client achieve the goal, then rearranging or implementing new ones may be necessary. The data presented are relevant for the diagnosis selected in this case, and it is not necessary to modify the whole plan. It would also not be necessary to discard the whole plan and start over. Modifications may be the key to a successful outcome for the client. |
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A client is admitted for a scheduled, elective hip replacement after having pain and limited mobility for several years. The client's plan of care would most likely be taken from which of the following?
A) Standardized care plan B) Informal nursing care plan C) Formal nursing care plan D) Individualized care plan |
A
A standardized care plan is a formal plan that specifies the nursing care for groups of clients with common needs. For example, all clients undergoing hip replacement surgery would have basic, similar needs or problems such as pain, skin integrity disruption, risk for infection, decreased mobility, or risk for fall or injury. An informal nursing care plan is a strategy for action that exists in the nurse's mind. A formal nursing care plan is a written or computerized guide that organizes information about the client's care. An individualized care plan is tailored to meet the unique needs of a specific client-needs not addressed by the standardized plan. |
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A nursing student does not understand the difference between evaluation and assessment-both are ongoing, and both are areas of data collection. In order to differentiate between the two, the student should remember that:
A) Assessment is done at the beginning of the process. B) Evaluation is completed at the end of the process. C) The difference is in how the data are used. D) They are the same and there is no need to differentiate. |
C
Though the two processes overlap, there is a difference between the data collected. Assessment data are collected for the nurse to make a diagnosis and evaluate desired outcomes. Evaluation data are collected for the purpose of comparing them to prescribed goals and judging the effectiveness of the nursing care. Though assessment is the first phase of the nursing process and evaluation is the final, assessment is carried out during all phases. |
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A client is learning how to administer insulin. The nurse makes sure that the client understands how to activate the safety mechanism on the syringe to prevent needlestick injuries. This is an example of which of the guidelines for implementing interventions?
A) Encourage clients to participate actively in implementing nursing interventions. B) Adapt activities to the individual client. C) Implement safe care. D) Base nursing interventions on scientific knowledge, research, and standards of care. |
C
Showing the client how to avoid injury with needlesticks is part of implementing safe care. Encouraging clients to participate enhances their sense of independence and control. This particular activity, though, is more directed at safe care. Adapting activities would involve learning the client's beliefs, values, age, health status, and environment as factors that can affect the success of a nursing action. The nurse must be aware of scientific rationale, as well as possible side effects or complications of all interventions so that implementing them centers around specific knowledge and care standards. |
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At the end of the shift, the nurse is reviewing client documentation for the shift. Among the documentation entries the nurse checks, special attention is paid to the flow sheets and abnormal assessment findings for each client. This type of charting is an example of which of the following?
A) Charting by exception B) Focus charting C) SOAP charting D) Computerized documentation |
A
Charting by exception (CBE) is a documentation system in which only abnormal or significant findings or exceptions to norms are recorded. Flow sheets, standards of nursing care, and bedside access to chart forms are all incorporated into CBE. Computerized documentation is a way to manage the volume of information required in a client's chart, and different systems may include a variety of setups and programs. Focus charting is organized into data, action, and response sections, referred to as DAR. SOAP charting is a way to organize data and information in the client's record: S = subjective data; O = objective data; A = assessment; P = plan. |
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The goal statement for a client's care plan read as follows: Client will be able to state two positive aspects of rehab therapy by the end of the week. Which of the following is an appropriately written evaluation statement?
A) Goal not met, client able to state one positive aspect by the end of the week. B) Goal met, client able to state two positive aspects of therapy by week's end. C) Goal met, client able to state one positive aspect by the end of the week. D) Goal incomplete, client not able to positively state anything about rehab. |
B
An evaluation statement consists of two parts: a conclusion and supporting data. The conclusion is a statement that the goal/desired outcome was met, partially met, or not met. The supporting data are the list of the client responses that support the conclusion. In this situation, the goal was met if the client was able to state two positive aspects of rehab by the end of the week and the evaluation statement should reveal that. If the client can only state one or it takes longer than a week, then the goal could be partially met. Using the word "incomplete" is not appropriate for the evaluation statement. |
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The client, after receiving emergency treatment for an acute asthma attack, had diminished wheezing in both lungs. When utilizing focus charting, this information would be included in the _______________ section.
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RESPONSE
Focus charting is intended to make the client and client concerns and strengths the focus of care. The progress notes are organized into data (D), action (A), and response (R). The response category reflects the evaluation phase of the nursing process and describes the client's response to any nursing and medical care. The data section reflects the assessment phase of the nursing process and consists of observations of client status and behaviors, including data from flow sheets. The action category reflects planning and implementation and includes immediate and future nursing action. |
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A new graduate nurse was working with a nurse mentor during the first 3 months of employment. On one of the first days working alone, the nurse is assigned to care for a client with a new tracheostomy and must provide teaching to the client as well as the client's spouse. This nurse is not familiar with the teaching aspect. The best action for the nurse is to:
A) Do the best the nurse can by remembering what was taught in nursing school. B) Read the policy and procedure manual before the teaching session. C) Ask for a different assignment until the nurse feels comfortable with this one. D) Ask the nurse mentor to assist with the teaching after reviewing the procedure. |
D
When implementing some nursing interventions, the nurse may require assistance. In this case, the nurse lacks the knowledge or skills to implement a particular nursing activity (teaching). Reading and reviewing the policy and procedure are important, but should be followed up with asking for assistance. "Doing the best the nurse can" would not be acceptable and neither would asking for a different assignment. |
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A nurse is reviewing a client's chart in a facility that utilizes problem-oriented recording. In looking for the most recent physician orders, the nurse should look in which section?
A) Plan of care B) Progress notes C) Problem list D) Database |
A
The initial list of orders or plan of care is made with reference to the client's active problems in this type of charting. Physicians write physician orders or the medical care plan. Nurses write nursing orders or the nursing care plan. The database consists of all known information about the client upon admission. The problem list includes those identified problems, listed in the order in which they are identified. Progress notes are chart entries made by all health professionals involved in the client's care. |
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The nurse is teaching new parents how to bathe their baby for the first time. An action that allows the parents to feel in control of this situation would be when the nurse:
A) Gives lots of advice and suggestions about different methods. B) Lets the parents watch a video after the bath. C) Tells the parents everything the nurse is doing and why. D) Lets the parents bathe the baby with direction and guidance from the nurse. |
D
Active participation enhances a client's sense of independence and control. In this situation, the baby and parents will do best with future bathing times if they are allowed to complete the bath themselves. Explaining, watching a video, and giving advice or suggestions are all helpful, but do not provide the clients with a sense of independence and control in the situation. |
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The nurse understands that respect for the dignity of the client is extremely important in providing nursing care. Which of the following is an example of this aspect?
A) Allowing clients to complete their own hygienic cares when possible B) Providing all cares to all clients whenever possible C) Presenting information to the client's family about the client's condition D) Telling the other staff that the client is demanding, so they are able to meet the client's needs |
A
Respecting the dignity of each client enhances their self-esteem and is an important aspect of implementing interventions. Providing privacy and allowing clients to make their own decisions, or doing their own cares when possible, is a way of respecting dignity and increasing self-esteem. It is not necessary, nor appropriate, to provide all cares at all times. Telling peers and other staff members that a client is demanding is the nurse's opinion and should not be part of the reporting process. Information should be presented to other family members only with the consent of the client. |
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A client has been in the hospital for several days following a CVA (cerebrovascular accident). One of the diagnoses formulated for this client is Risk for aspiration, related to neuromuscular dysfunction. Of the following interventions, which includes a rationale?
A) Provide frequent assessment for presence of obstructive material in mouth and throat. B) Clear secretions from oral/nasal passageways as needed. C) Have suction equipment available at all times. D) Keep client in low-Fowler's position to prevent reflux. |
D
A rationale is the scientific principle given as the reason for selecting a particular nursing intervention. It helps explain "why" an intervention would be implemented. Keeping the client in a position with the head elevated 30 to 45 degrees helps prevent the risk of reflux (food/liquids returning up through the esophagus after having been swallowed). None of the other options state "why" they are being performed. |
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A nursing diagnosis of Fluid volume deficit, related to active fluid loss, secondary to diarrhea has been formulated for a client. An appropriately written goal statement for this diagnosis would be which of the following?
A) Client will have good skin turgor. B) Client will have intake of at least 1000 mL within 24 hours. C) Client will have moist mucous membranes. D) Client will drink more fluids by tomorrow. |
B
The goal statement must be specific with observable outcomes in order for the nurse to evaluate client progress. Modifiers like "more" and "good" could be more specific, and all options must have a time frame for evaluating the desired performance. |
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A nurse works in an acute psychiatric setting and sees clients as they are admitted for inpatient psychiatric care. Many of the clients exhibit paranoid behavior. The most important skill this nurse can utilize for these clients is which of the following?
A) Cognitive skill B) Technical skill C) Interpersonal skill D) Therapeutic skill |
C
Interpersonal skills are all of the activities, verbal and nonverbal, people use when interacting directly with one another. The effectiveness of a nursing action often depends largely on the nurse's ability to communicate with others. Interpersonal skills are necessary for all nursing activities including comforting, counseling, and supportingall of which are extremely important in the acute psychiatric setting. Cognitive skills are intellectual skills and include problem solving, decision making, critical thinking, and creativity. Technical skills are "hands-on" skills such as manipulating equipment, giving injections, bandaging, and repositioning clients. |
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A nurse works in a hospital that utilizes a charting by exception documentation system. When providing care and performing assessments, the nurse may not address all of the sections on a client's flow sheet, especially if the client did not require this particular care. In order for the nurse to identify that these areas were addressed, but no care was needed, the best action is to:
A) Make sure this information gets passed along in the shift report. B) Leave them blank, but then add an extensive explanation in the progress notes section of the chart. C) Write N/A on the flow sheet in the areas that are not applicable to that client. D) Leave them blank. |
C
Many nurses are uncomfortable with the CBE system and believe that if something was not charted, it was not done. A suggestion to address this would be to write N/A on the flow sheets where the items are not applicable to the client, and not leave the spaces blank. This would avoid the possible assumption that the assessment or intervention was not done by the nurse. It is never a good idea to leave blanks in any charting area. Passing information along in the report is a good way to ensure continuity of care for clients, but this would only be an oral report, not written documentation. |
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A client has been seeing a nurse practitioner for counseling following a rape. A long-term goal for this client would be which of the following?
A) Client will return to level of purpose and functioning as before the rape. B) Client will state signs and symptoms of physical trauma. C) Client will devise a list of phone numbers for support people. D) Client will be able to share feelings of fear with counselor. |
A
Clients who have been raped may require extensive counseling and therapy work to deal with the assault. Some may never regain their prior level of functioning as before the attack, and for most, it will require some time to do this. Short-term goals are the other options listedthose that the client can implement in the first few days following the rape in order to feel safe and share feelings of fear and anger. The physical injuries following a rape may be minor, but the client should know to watch for any unusual symptoms (i.e., discharge, bruising, or bleeding). |
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The client is admitted to a comprehensive rehabilitation center for continuing care following a motor vehicle crash. The admitting nurse will develop the initial plan of care. Of the following, who might be involved with the ongoing planning of this client's care?
A) Everybody involved in this client's care B) The client and the client's support system C) All nurses who work with the client D) The admitting nurse is still responsible |
A
Planning is basically the nurse's responsibility but input from the client and support persons is essential if a plan is to be effective. In this case, therapies from other disciplines (occupational, physical, speech, etc.) would be involved since the client is in a comprehensive rehabilitation center. The client's support people and caregivers are also going to be involved in the plan of care, but not exclusively. |
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A student nurse is reviewing an assigned client's chart. When trying to locate recent lab results, the student notices that each department has a separate section in the chart. This type of documentation system is called which of the following?
A) Problem-oriented record B) Case management C) Source-oriented record D) Focus charting |
C
The traditional client record is a source-oriented record in which each person or department makes notations in a separate section or sections of the client's chart. In the problem-oriented medical record, the data are arranged according to the problems the client has rather than the source of the information. Case management uses a multidisciplinary approach to documenting client care, called critical pathways. Focus charting is intended to make the client and client concerns the focus of care, utilizing a three-column format. |
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A client in long-term care is scheduled for a review of the assessment and care screening process. This assessment will be documented in which of the following?
A) OBRA B) MDS C) CBE D) Kardex |
B
The Minimum Data Set (MDS) for assessment and care screening must be performed within 4 days of a client's admission to a long-term care facility and reviewed every 3 months. Laws influencing the kind and frequency of documentation required are the Health Care Financing Administration and the Omnibus Budget Reconciliation Act (OBRA) of 1987. It is under the OBRA law that the MDS is identified. CBE stands for charting by exception. The Kardex is a system of organizing client information so it can be accessed quickly. It is usually used in the acute care area. |
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A cardiac specialty hospital has several written plans in place for clients who are admitted, according to specific medical diagnoses and nursing interventions. Typical nursing diagnoses as well as standard nursing interventions are included in these plans. This hospital is utilizing which of the following?
A) Kardex B) Critical pathways C) Standardized care plans D) Traditional care plans |
C
Standardized care plans were developed to save documentation time. These plans may be based on an institution's standards of practice, thereby helping to provide a high quality of nursing care. Standardized care plans are usually individualized to address each client's specific needs. Traditional care plans are written for each client, are specific, and are individualized for that client. Critical pathways are used in case management, involving a multidisciplinary approach to planning and documenting client care. The Kardex is a concise method of organizing and recording data about a client-making information quickly accessible for all health professionals. |
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A client with Parkinson's disease is working to improve fine motor skills, especially for completing activities of daily living. Which of the following would be considered a collaborative intervention?
A) Provide assistance as needed with dressing and grooming. B) Provide assistive devices and educate client to use grab bar and large handled utensils. C) Administer medications to improve muscle tone. D) Make sure lighting and space are adequate for client. |
B
Collaborative interventions are actions the nurse carries out with other health team members, such as physical therapists, social workers, dietitians, and physicians. Collaborative nursing activities reflect the overlapping responsibilities of, and collegial relationships between, health personnel. Providing assistive devices and educating on their proper use would fall into the discipline of physical/occupational therapy, although the nurse will have to assist with reinforcing the teaching and information. Providing assistance and attending to the client's space would be independent interventions. Administering medications would be a dependent intervention. |
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A nursing diagnosis of Risk for Deficient Fluid Volume related to excessive fluid loss, secondary to diarrhea and vomiting was implemented for a home health client who began with these symptoms 5 days ago. A goal was that the client's symptoms would be eliminated within 48 hours. The client is being seen after a week, and has had no diarrhea or vomiting for the past 5 days. The nurse should:
A) Keep the problem on the care plan, in case the symptoms return. B) Assume that whatever the cause was, the symptoms may return, but document that the goal was met. C) Document that the potential problem is being prevented since the symptoms have stopped. D) Document that the problem has been resolved and discontinue the care for the problem. |
D
In this case, the risk factors no longer exist because the causative factors have stopped. The nurse should document that the goal has been met and discontinue the care for the problem. If the problem returns, it can be implemented again and addressed at that time. |
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A nurse is working in a busy research hospital. One of the clients assigned to the nurse's care is to receive a medication that the nurse is not familiar with and is not listed in the drug reference manual. The best action of the nurse is to:
A) Ask the client about this medication. B) Follow the physician's orders as written and give the medication. C) Call the physician and ask what the medication is and what it is for. D) Call the pharmacy and do further investigating before administering the medication. |
D
The nurse should clearly understand all nursing interventions to be implemented and question any that are not understood. The nurse is responsible for intelligent implementation of medical and surgical plans of care. Following the physician's order is important, but the nurse is still responsible to know and understand the medication, its action, and adverse actions as well as interactions with other medications. The client should be informed about the medications and treatments, but the nurse does not utilize the client for scientific knowledge and professional standards of care. The pharmacist would be the most appropriate reference point for this nurse to begin to research this problem. |
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A client has just given birth to a premature infant via emergency C-section. Which of the following nursing diagnoses would receive the lowest priority for the new mother?
A) Risk for infection, related to surgical incision B) Impaired skin integrity, related to new incision C) Acute pain, related to surgical procedure D) Anxiety, related to unpredictability of newborn's health |
A
A problem identified as potential (at risk for development) receives the lowest priority since it is currently not present. It is a potential for this client and therefore must be assessed and monitored as a possible complication. The other options are active problems and would receive a higher priority for care. |
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The student nurse must accurately perform a sterile dressing change before completing a unit of the course. This student is being evaluated on which of the following?
A) Technical skill B) Interpersonal skill C) Academic skill D) Cognitive skill |
A
Technical skills are "hands-on" skills such as manipulating equipment, giving injections, bandaging, moving, lifting, and repositioning clients. These skills can also be called tasks, procedures, or psychomotor skills. Cognitive skills are intellectual skills that involve problem solving, decision making, critical thinking, and creativity. Interpersonal skills are necessary for all nursing activities: caring, comforting, advocating, referring, counseling, and supporting, to name a few. Academic skills would fall under the category of cognitive skills. |
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A client who has been hospitalized for a period of time is now being transferred to a rehabilitation center for more long-term care. As he is preparing to be discharged, the client asks the nurse if he can take his chart with them, since it's his record. The nurse responds correctly by saying:
A) "We'll make sure that all of your records are sent ahead to the rehab hospital, so you don't really have to worry about those details." B) "Actually, the original record is the property of the hospital, but you are welcome to copies of your records." C) "There's a new law that protects your records, so you're not going to be able to have access to them." D) "You'll have to ask your doctor for permission to do that." |
B
Although the client's record is protected legally as private, access to the record is restricted to health professionals involved in the client's care. The institution or agency is the rightful owner of the client's record, but the client has the right to access all information contained within his own record and to have a copy of the original record. The hospital has the right to charge a fee for the copying costs. The Health Insurance Portability and Accountability Act (HIPAA) is a law enacted to protect health information and maintain confidentiality of client records. |
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A client did not meet the goal of walking unassisted, without assistive devices, by discharge from rehabilitation. The case manager using a critical pathway would identify this as which of the following?
A) An error in judgment on the case manager's part B) A variance C) An unattainable goal D) An incorrectly written care plan |
B
Critical pathways are a multidisciplinary approach to planning and documenting client care. Flow sheets, as well as some types of charting by exception, are utilized in critical pathways. When a goal is not reached, it is called a variance. Variances are deviations to what is planned in the critical pathwayunexpected occurrences that affect the planned care or the client's response to care. In this case, the client may need more time or different interventions to reach the goal. The goal and problem may be appropriate, but the interventions may need to be adjusted. |
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A nurse has provided routine morning cares to a client, including all the medications and scheduled treatments. The most appropriate action after this is completed is for the nurse to:
A) Get supplies organized for the next client's medications and treatments. B) Document all cares in the progress notes. C) Move on to the next assignment to increase the nurse's efficiency. D) Report this to the charge nurse. |
B
After carrying out the nursing activities, the nurse completes the implementing phase by recording the interventions and client responses in the progress notes. Administering medications should be recorded when completed to prevent errors. At times, documentation may be done at the end of the shift, but in some instances, as in medication administration, it is important to record immediately after implementation. This information must be accurate and up to date for other nurses and health care professionals. Reporting to the charge nurse would be done at the end of the shift, unless the client's condition is not stable. |
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A community health nurse is testing the theory of locus of control (LOC). Which of the following clients demonstrates the internal control concept of this theory?
A) A client who allows the primary care provider to make all the decisions B) A client who relies on information from the local hospital for his or her health needs C) A client who does not make any decisions without his or her spouse's input D) A client who takes an active role in all health decisions |
Locus of control (LOC) is a concept from social learning theory. People who exercise internal control are more likely than others to take the initiative on their own health care and to be more knowledgeable about their health. They are also more likely to adhere to prescribed health care regimens such as taking medication, making and keeping appointments with physicians, maintaining diets, and giving up smoking. People who believe their health is largely controlled by outside forces (chance or others) are referred to as externals.
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The nurse who is assisting a client in the action stage of change would use which of the following strategies?
A) Reinforce the importance of providing rewards for positive behavior B) Ask the client if they would like information C) Guide the client to create a plan of action D) Remind the client of previous successes |
A
Correct, Answer B is a strategy for the contemplation stage, C is a strategy for the preparation stage, and D is a strategy for the maintenance stage. |
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Two people have been in a MVA (motor vehicle accident) and have similar injuries. According to the transaction-based model, their degrees of stress from the accident will be:
A) Completely individual based on previous experiences and personal characteristics B) Extremely similar since they had the same stimulus C) The identical physiologic alarm reaction D) Different depending on their external resources and support levels |
A
Correct, in the Transaction Model, stress is a very personal experience and varies widely among individuals. Answer B represents the Stimulus Model, C the Response Model of Stress. External resources and support are a factor in determining stress levels but omit the key aspects of internal/personal influences. |
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Which of the following examples is an example of the emotional component of wellness?
A) The client chooses health foods B) A new father decides to take parenting classes C) A client expressess frustration with her spouse's substance abuse D) A widow with no family decides to join a bowling league |
C
Correct, Frustration is an example of an emotion. The client who chooses healthy foods represents the physical component, taking parenting classes enhances the intellectual component, and the bowling league is both physical and social components. |
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Which of the following individuals appears to have taken on the sick role?
A) An obese client states "I deserve to have a heart attack" B) A mother is ill and says, "I won't be able to make your lunch today" C) A man with low back pain misses several physical therapy sessions D) An elder states, "My horoscope says that I will be well again" |
B
Correct, the mother has taken on the sick role by expecting to be excused from her usual role responsibilities. The sick role states that persons are not answerable for their illness, contrary to the obses client's perspective. In the sick role, the client tries to get better as opposed to the man who misses his physical therapy appointments. The elder is not following the sick role expectation to rely on competent help. |
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Which of the following statements reflect the contemplation stage of behavior change?
A) "I currently do not exercise 30 minutes three times a week and do not intend to start in the next six months" B) "I have tried several times to exercise 30 minutes three times a week but am seriously thinking of trying again in the next month" C) "I currently do not exercise 30 minutes three times a weeks, but am thinking about starting to do so in the next six months" D) "I have exercised for 30 minutes three times a week regularly for more than six months" |
C
Correct, Answer A reflects the precontemplation stage, B the planning stage, and D the maintenance stage. |
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When you take your cleint's temperature at 8:00 am using an oral electronic thermometer, the result is 36.1o C (92.2 o F). All other vital signs are within normal range. What would you do next?
A) Wait 15 minutes and retake it B) Check what the cleint's temperature was the last time C) Retake it with a different thermometer D) Chart the temperature, it is normal |
B
Correct, The temperature is pretty low, even for the morning. It would be best to see what the client's "usual" temperature has been. Maybe he or she usually has a low temperature. Depending on that finding, you might want to retake it with another thermometer to see if yours is functioning correctly. If everything checks out, chart it and check that the client has no signs of hypothermia. (remember, the question what "what would you do next") |
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The nurse case manager is concerned about a particular client being discharged from the hospital. Which of the following factors, if present for this client, would alert the nurse to possible problems with treatment adherence?
A) The client has not had difficulty understanding the regimen. B) The therapy will require no lifestyle changes of the client. C) The client's culture is supportive of Western medicine. D) The prescribed therapy is costly and of unknown duration. |
D
Adherence to a particular therapy can be compromised if the therapy is expensive or if the complexity, side effects, and duration of the proposed therapy are large. Other factors influencing adherence include client motivation to become well; degree of lifestyle change necessary; perceived severity of the health care problem; value placed on reducing the threat of illness; difficulty in understanding and performing basic behaviors; degree of inconvenience of the illness itself or of the regimen; beliefs that the prescribed therapy or regimen will or will not help; complexity, side effects, and duration of the proposed therapy; specific cultural heritage that may make adherence difficult; and degree of satisfaction with the quality and type of relationship with the health care providers. |
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A patient with HIV infection will be starting on combination medications to manage her disease. As you discuss the medication schedule, you know all of the following predict improved adherence EXCEPT:
A) Her educational level B) A trusting relationship with her provider C) An expectation that the medication will be helpful D) Being able to take the medications twice daily instead of four times a day |
A
Correct, education has not been shown to be a factor in predicting adherence. There is good evidence that a trusting relationship with her provider, evidence supporting the effectiveness of the medication, and a less complex dosing regime are important predictors. |
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A female patient is 46 pounds overweight. She previously attended two programs that "guaranteed" weight loss. Although the weight was lost, more returned after each program. She tells you, " I was just born to be fat. I don't have the willpower." According to the Health Promotion Model, the nurse recognizes which of the behavior-specific cognitions and affect variable in this client?
A) Perceived barriers to action B) Perceived self-efficacy C) Interpersonal influences D) Situational influences |
B
Correct, Perceived self-efficacy is the confidence the person has for achieving the desired outcome. Answer A is a person's perception about available time, inconvenience, expense, and difficulty performing the activity; C is the person's perception concerning the behaviors, beliefs, or attitudes of others; and D refers to the person's perception of the environment and how it assists or detracts from the healthy behaviors. |
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A nurse has volunteered to go on a health mission to rural Haiti, where the majority of the people do not have access to health care and live in poverty. According to Dunn's high-level wellness grid, the nurse will be working with clients in which quadrant?
A) Protected poor health in an unfavorable environment B) Emergent high-level wellness in an unfavorable environment C) Poor health in an unfavorable environment D) Protected poor health in a favorable environment |
C
According to Dunn's grid, the health axis extends from peak wellness to death, and the environmental axis extends from very favorable to very unfavorable. A health mission to an environment such as rural Haiti would involve clients who are not being treated for problems because of poor access and who also live in poor environmental conditions such as poverty and below standard sanitation. Emergent high-level wellness in an unfavorable environment would include clients who have the knowledge to implement healthy lifestyle practices, but cannot implement them because of other factors or demands. Protected poor health in a favorable environment is where clients have an illness but their needs are met by the health care system. These clients have adequate access to appropriate medications, diet, and health care instruction. Protected poor health in an unfavorable environment is not one of Dunn's quadrants. |
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Which of the following clients is exhibiting a level of Kalish’s adaptation of Maslow’s hierarchy? The client who:
A) Has a need to participate in school sports and be “on the team.” B) Is sleep deprived because of musculoskeletal discomfort. C) Strives to become the CEO of a company. D) Has a homosexual encounter for the first time. |
d
Richard Kalish added a sixth level to Maslow’s five levels and referred to it as stimulation needs. This level includes sexual activity, exploration, manipulation, and novelty. A client who “wants to be on the team” is exhibiting characteristics of love and belonging needs. Striving to be in charge of a company is part of self-actualization, and sleep is one of the basic physiological needs. |
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Which factors impact health promotion and illness prevention with the elderly? (Select all that apply.)
A) Presence of one or more chronic diseases B) Supportive family C) Change in cognitive status D) Increase in physical limitations |
A, C, D
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Psychologic homeostasis is maintained by a variety of mechanisms. Which of the following clients is the most likely candidate to obtain psychologic homeostasis?
A) An elderly person who has just moved to a long-term care facility B) A teenager whose circle of friends includes single parents of the same age C) A child who is used to getting ready for school alone D) A young adult who is in a long-term relationship |
D
Psychologic homeostasis is acquired or learned through the experience of living and interacting with others. Individuals can develop psychologic homeostasis if they are in a stable physical environment where they feel safe and secure (a child who is alone while getting ready for school may not feel safe and secure). Individuals also need a stable psychologic environment from infancy onward so that feelings of love and trust develop, a social environment that includes adults who are healthy role models, and a life experience that provides satisfaction. Having friends of the same age who are parents may eliminate healthy adult role models for the teenager. Moving into a long-term care facility can be a huge adjustment for some people, which may affect feelings of safety and security. A young adult who has a relationship that lasts is the one option that would fit most of these mechanisms. |
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The client is a high school student who is also a single parent. She is attending parenting classes while studying full time and living in an apartment with her child. The student also meets twice a week with a teen peer group and participates in a nutrition program through the county. Which of the following is the most appropriate diagnosis for this client?
A) Risk for Situational Low Self-Esteem B) Readiness for Enhanced Nutrition C) Readiness for Enhanced Coping D) High Risk for Caregiver Role Strain |
C
Wellness diagnoses describe the human responses to levels of wellness in an individual. In this situation, even though the client is young and single, she is making every effort to be well in her situation. Attending parenting classes, meeting with peers, and learning about nutrition all point to a person who has a positive outlook but requires teaching. The information given in the scenario does not indicate that the client is experiencing problems of self-esteem or role strain. The client is doing much more than just learning about nutrition. She is learning how to cope and be well in her life and the life of her child. |
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A client is noncompliant about adhering to dietary restrictions designed to manage his diabetes. Which statement by the nurse would be most likely to motivate the client to comply with treatment?
A) "I don't understand why you don't follow your diet." B) "I understand that following this diet is hard for you. Can you share with me why this has been difficult?" C) "Not following your diet may shorten your life." D) "Let me review your diet with you again, because you don't seem to understand it." |
B
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A client has failed to follow the plan that was developed for health promotion. What would be the most effective response by the nurse?
A) Inform the physician of the client's lack of motivation. B) Discard the idea that the client must change. C) Discharge the client due to noncompliance. D) Start over at the beginning of the process. |
B
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A client has received a high score on the Life-Change Index. This component would be part of which of the following?
A) Health beliefs review B) Lifestyle assessment C) Life stress review D) Social support systems review |
C
The Life-Change Index is a tool that assigns numerical values to life events and is a way to identify clients in stress. Studies have shown that high levels of stress are associated with an increased possibility of illness in an individual. A social support systems review takes into account the social context in which a person lives and works. A lifestyle assessment focuses on the personal lifestyle habits of the client as they affect health. A health beliefs review provides information about how much clients believe they can influence or control health through personal behaviors. |
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A nurse is delivering a workshop regarding health promotion to a group of elderly clients. In describing Healthy People 2010, which of the goals will the nurse emphasize for this group?
A) Developing partnerships between individual and community health B) Increasing quality and years of life C) Eliminating health disparities D) Believing that individual health is closely related to community health |
B
Healthy People 2010 has two main goals. The first is to increase quality and years of healthy life, which applies to the clients who will be the focus of this workshop. The second goal is to eliminate health disparities, which reflects the diversity of the population. The foundation for this document is the belief that individual health is closely linked to community health and the reverse. In order to bring this about, partnerships are important to improve the health of individuals and communities. |
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Which of the following problems should be given the highest priority using Maslow’s hierarchy of needs?
A) Social isolation B) Malnutrition C) Racism D) Sexual dysfunction |
B
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A client at a cardiology clinic is having difficulty following his low-fat diet. Which of the following actions by the nurse would be least likely to foster compliance from this client?
A) Using teaching aids, such as pamphlets B) Motivating the client by telling him that he'll be dropped from the clinic if he doesn't follow the diet C) Demonstrating caring by asking about the client's home situation. D) Establishing a therapeutic relationship by using her knowledge and skills. |
B
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A client is hospitalized with numerous acute health problems. According to Maslow’s basic needs model, which nursing diagnosis would take the highest priority?
A) Powerlessness related to chronic disease state B) Risk for Injury related to unsteady gait C) Self-Care Deficit related to weakness and debilitation D) Altered Nutrition, Less than Body Requirements related to inability to absorb nutrients |
D
In needs theories, human needs are ranked on an ascending scale according to how essential the needs are for survival. Physiologic needs are those such as air, food, water, shelter, rest, sleep, activity, and temperature maintenance, which are all crucial for survival. Nutritional deficits would fall into this level and take priority over the others listed. Self-Care Deficit would fall in the fourth levelself-esteem needs. Powerlessness is part of the need to develop one’s maximum potential. It falls into the fifth and highest level of self-actualization. A potential problem is one that is likely unless interventions are provided. Since the situation does not exist at this time, Risk for Injury would be the lower priority need. |
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The nurse is assisting a client and his family after the client had a stroke and is no longer able to return to his previous employment. The nurse has made a referral to vocational rehabilitation for assistance in retraining the client in a different occupation. Which component of wellness is the nurse assisting in for this client?
A) Environmental B) Occupational C) Emotional D) Intellectual |
B
Occupational components deal with a balance between work and leisure time. A person's beliefs about education, employment, and home influence personal satisfaction and relationships with others. Assisting a client in retraining to find gainful employment and to attain satisfaction in his work is part of the occupational component of wellness. The intellectual component focuses on learning and using information effectively for personal, family, and career development. It also involves striving for continued growth and learning to deal with new challenges effectively. Because the client requires retraining, he must learn anew those aspects of a job that allow for growth, which would better fit under the occupational component of wellness. Environmental components focus on standards of living and quality of life in the community and include basic human needs such as water, air, and food. Emotional components of wellness involve the ability to manage stress and express emotions appropriately. |
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The health nurse of a busy university campus is implementing a health promotion activity by placing posters about proper hand washing in all of the public restrooms on campus. This is an example of which type of health promotion program?
A) Information dissemination B) Health risk appraisal and wellness assessment C) Environmental control D) Lifestyle and behavior change |
A
Information dissemination is the most basic type of health promotion program. This method makes use of a variety of media to offer information to the public about the risk of a particular lifestyle choice and personal behavior as well as the benefits of changing that behavior. Environmental control programs have been developed as a result of the continuing increase of contaminants of human origin that have been introduced into the environment. Health risk appraisal and wellness assessment programs are used to describe risk factors to people and motivate them to reduce specific risks and develop positive health habits. Lifestyle and behavior change programs require participation of the individual and are geared toward enhancing the quality of life and extending life span. |
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A client is learning how to manage his asthma. In providing teaching, the nurse stresses the importance of using the peak flow meter every morning to help determine changes in respiratory status. The nurse is stressing which of the following behaviors of health promotion?
A) Situational influences B) Competing preferences C) Competing demands D) Interpersonal influences |
B
Competing preferences are behaviors over which an individual has a high level of control and depend on the individual’s ability to be self-regulating. In this case, the individual must make a choice to use his peak flow meter every day. It’s really his choiceeither he uses it or he doesn’t. Competing demands are behaviors over which an individual has a low level of control; something unexpected competes with a planned activity. Situational influences are direct and indirect influences on health-promoting behaviors and include perceptions of available options, demand characteristics, and the aesthetic features of the environment. Interpersonal influences are a person’s perceptions concerning the behaviors, beliefs, or attitudes of others. |
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A client has had a severe brain injury and has been in a rehab hospital for several months. Recently, the client developed pneumonia and is currently on IV antibiotic therapy for this. Which level of prevention addresses the pneumonia?
A) Tertiary B) Acute C) Primary D) Secondary |
D
Secondary prevention emphasizes early detection of disease, prompt intervention, and health maintenance for individuals experiencing health problems. Because the pneumonia is a current health problem, interventions focused on that would be considered secondary prevention. All cares related to rehabilitation following the brain injury would be tertiary prevention. Tertiary prevention focuses on rehabilitating individuals to an optimum level of functioning. Primary prevention is true health promotion and provides specific interventions against disease. Acute care is a part of health care, but not one of the levels of prevention. |
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Several nursing students have been discussing the benefits of joining a study group. They realize the importance of applying nursing knowledge to the clinical area and figure that together they may be more effective in retaining this information than if they continued in their individual settings. Which stage of behavior change are they exemplifying?
A) Termination stage B) Contemplation stage C) Preparation stage D) Action stage |
B
During the contemplation stage, the person acknowledges the problem, considers changing a specific behavior, actively gathers information, and verbalizes plans to change the behavior in the near future. Discussing benefits of a study group would fall into this stage. They haven’t started a group nor have they made any preparation toward it; they have merely been talking about it. The termination stage is the ultimate goal where the individual has complete confidence that the problem is no longer a temptation or threat. The preparation stage occurs when the person undertakes cognitive and behavioral activities that prepare the person for change. The action stage occurs when the person actively implements behavioral and cognitive strategies to interrupt previous behavior patterns and adopt new ones. |
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The two major goals of Healthy People 2010 reflect the nation's changing demographics. These goals include which of the following?
A) Increase community health centers B) Implement programs that modify the environment and behaviors C) Increase quality and years of healthy life and eliminate health disparities D) Increase illness-prevention strategies in the general population |
C
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A nurse in charge of an assisted living complex that includes independent living apartments understands the unique needs of individuals of this age group. In planning health promotion strategies, the nurse takes which of the following factors into consideration?
A) Adjusting to physiologic changes and limitations B) Rest and exercise C) Safety promotion and injury prevention D) High obesity percentages |
A
In the elderly population, health promotion and illness prevention are important, but the focus is often on learning to adapt to and live with increasing changes and limitations. Maximizing strengths continues to be of prime importance in maintaining optimal function and quality of life. Rest and exercise are life span considerations of children as are high obesity percentages. Safety promotion and injury prevention are life span considerations for adolescents. |
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A 63-year-old client with diabetes depends on her husband and daughter to bring her to the clinic. She refuses to give herself insulin, and complains to the nurse, "I don't understand why my blood sugar is always so high." What should the nurse consider when providing diabetic teaching for this client?
A) The client is probably externally controlled, and may need help to assume responsibility for her own health. B) The client is probably externally controlled, and therefore will be able to take responsibility for her own health. C) The client's husband will need to take control of her health care. D) The client is probably internally controlled, and therefore will be able to take the initiative for her own health care. |
A
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Which intervention would be least effective when assisting a client in making behavior changes that would reduce his health risk factors?
A) Ask the client to follow a plan you wrote for him. B) Have the client identify two or three goals for change C) Help the client to develop a plan for change D) Allow the client to set a reasonable time frame for change. |
A
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According to Prochaska, Norcross, and DiClemente (1994), which stage in health behavior change would include the client's acknowledging a problem?
A) Precontemplation stage B) Contemplation stage C) Preparation stage D) Action stage |
B
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During a Nursing Health History the goals of obtaining an exposure history are:
A) Identifying past and present toxic exposures B) Ending the patient's exposure to toxins C) Giving the patient a reason to initate litigation with the exposure source D) Identifying safety Hazards to the patient |
A, D
Identifying ( Assessing for) past and present toxic exposures, occupational or recreational, may give important clues as to the patient's current health status |
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The nurse is preparing information packets for incoming college students regarding sexually transmitted disease, drug and alcohol abuse, and the use of stimulants among this age group. In this situation, the nurse has assumed which of the following roles?
A) Advocate B) Coordinator of services C) Teacher D) Facilitator |
C
The teaching role focuses on self-care strategies such as enhancing fitness, improving nutrition, managing stress, and enhancing relationships. A facilitator is involved in the assessment, implementation, and evaluation of health goals. The advocate helps implement changes that promote a healthy environment. A coordinator helps to guide and reinforce the client’s development in effective problem solving and decision making as well as reinforces personal and family health-promoting behaviors. |
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Which nursing diagnoses are included in the NANDA taxonomy for a wellness diagnosis? (Select all that apply.)
A) Readiness for enhanced spiritual well-being B) Readiness for enhanced knowledge C) Readiness for enhanced parenting D) Readiness for discharge |
A, B, C
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The nurse case manager is concerned about a particular client being discharged from the hospital. Which of the following factors, if present for this client, would alert the nurse to possible problems with treatment adherence?
A) The client has not had difficulty understanding the regimen. B) The therapy will require no lifestyle changes of the client. C) The client's culture is supportive of Western medicine. D) The prescribed therapy is costly and of unknown duration. |
D
Adherence to a particular therapy can be compromised if the therapy is expensive or if the complexity, side effects, and duration of the proposed therapy are large. Other factors influencing adherence include client motivation to become well; degree of lifestyle change necessary; perceived severity of the health care problem; value placed on reducing the threat of illness; difficulty in understanding and performing basic behaviors; degree of inconvenience of the illness itself or of the regimen; beliefs that the prescribed therapy or regimen will or will not help; complexity, side effects, and duration of the proposed therapy; specific cultural heritage that may make adherence difficult; and degree of satisfaction with the quality and type of relationship with the health care providers. |
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A nurse educator takes students into the school system and provides developmental testing for kindergarten through third grade. The nurse educator and students are providing care at which level of prevention?
A) Tertiary B) Community C) Secondary D) Primary |
C
Secondary prevention emphasizes early detection of disease and health maintenance for individuals experiencing health problems. This would include providing assessment of the growth and development of children. Primary prevention is true health promotion and precedes disease or dysfunction. Tertiary prevention begins after an illness, when a defect or disability is fixed, stabilized, or determined to be irreversible. Community health is a broad category that includes many facets. It is not a level of prevention. |
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Which of the following descriptions best fits the Eudaemonistic model of health?
A) Health is defined in terms of the individual's ability to fulfill societal roles. B) Health is a process of adaptation. C) Health is identified by the absence of disease or injury. D) Health is the realization of a person's potential. |
D
eudaemonistic model most comprehensive, holistic, view of health; ability to become self-actualized essential to the model health is actualization or realization of one’s potential illness is seen as the failure to actualize or realize one’s potential |
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A nurse educator is explaining the concept of health and parallels this with interruption of body systems and symptoms of disease or injury. This educator is interpreting health according to which model?
A) Adaptive B) Clinical C) Eudemonistic D) Health-illness continua |
B
The narrowest interpretation of health occurs in the clinical model, where people are viewed as physiologic systems with related functions and health is defined by the absence of signs and symptoms of disease or injury. The health-illness continua is often used to measure a person's perceived level of wellness in which health and illness are at opposite ends of a health continuum. The eudemonistic model incorporates a comprehensive view of health, where health is seen as a condition of actualization or realization of a person's potential. In the adaptive model, health is seen as a creative process and disease is seen as a failure in adaptation or maladaptation. |
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An otherwise healthy 59-year-old client is hospitalized with multiple fractures of the lower extremities after an automobile accident. Where would this client be placed on Dunn's high-level wellness grid?
A) Protected poor health in a favorable environment B) Poor health in an unfavorable environment C) Emergent high-level wellness in an unfavorable environment D) High-level wellness in a favorable environment |
A
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A client states that her cancer is the result of punishment from God for her sins. This client will most likely be:
A) A passive recipient of health care B) Rigidly compliant to all aspects of the treatment regimen C) Interested in alternative therapies for her cancer D) Highly motivated to seek health care |
A
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When working within the total care context of the individual, the nurse considers which of the following?
A) The person’s self-identity B) Principles that are applicable to the client at this moment C) Principles that are general to all clients of the same age and condition D) The individualism of the client |
C
In the total care context, the nurse considers all the principles and areas that apply when taking care of any client of that age and condition. In the individualized care context, the nurse becomes acquainted with the client as an individual, referring to the total care principles and using those principles that apply to this person at this time. The person’s self-identity is part of the individual health dimension of any one client. |
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The client is making a list of past experiences that have brought joy, peace, and hope into the client’s life. This is part of which of the following?
A) Health beliefs review B) Lifestyle assessment C) Social support systems review D) Spiritual health assessment |
D
Spiritual health is the ability to develop one’s spiritual nature to its fullest potential, including the discovery of how to experience love, joy, peace, and fulfillment. An assessment of spiritual well-being is a part of evaluating the person’s overall health. Lifestyle assessment focuses on personal lifestyle and habits of the client as they affect health. Physical activity, nutritional practices, and stress management would be included in a lifestyle assessment. A social support systems review takes into account the social context in which a person lives and works and is important in health promotion. This includes individuals, groups, and interpersonal relationships that provide comfort, assistance, encouragement, and information. A health beliefs review is a clarification of those beliefs that determine how a person maintains control of his or her own health status. |
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When performing a health risk assessment, it is important to remember that this assessment is intended to indicate the client's risk over how many years?
A) Two years B) Five years C) Ten years D) Twelve years |
C
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A client has joined a fitness club and is working with the nurse to design a program for weight reduction and increased muscle tone. The client has tried exercise in the past with success, but has not been participating in a program for some time. In order to assess the potential for success with this client, the nurse should evaluate which of the behavior-specific cognitions?
A) Perceived self-efficacy B) Perceived benefits of action C) Situational influences D) Interpersonal influences |
B
Behavior-specific cognitions and affect are considered to be of major motivational significance for acquiring and maintaining health-promoting behaviors. Perceived benefits of action affect the person’s plan to participate in health-promoting behaviors and may facilitate continued practice. If this client has prior positive experience with the behavior or observations of others engaged in the behavior, he or she may be motivated to success. Interpersonal influences are a person’s perceptions concerning the behaviors, beliefs, or attitudes of othersincluding family, peers, and health professionals who can influence their success. Situational influences are direct and indirect influences on health-promoting behaviors and include perceptions of options, demand characteristics, and the aesthetic features of the environment. Perceived self-efficacy refers to the conviction that a person can successfully carry out the behavior necessary to achieve a desired outcome. |
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An occupational health nurse is surveying employees. Which of the following employees would be predisposed to develop an illness?
A) An employee who is in a middle-management position and takes stress from administration as well as the employees B) An employee who works 4 days on and 3 days off C) An employee who works in the janitorial department D) An employee who works 12-hour days, 3 days a week |
A
Some industrial workers may be exposed to carcinogenic agents. People who hold management positions are in stressful occupational roles that predispose them to stress-related diseases. Working as a custodian or longer shifts would not pose the same type of stress as the management position. |
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A community health nurse is testing the theory of locus of control (LOC). Which of the following clients demonstrates the internal control concept of this theory?
A) A client who allows the primary care provider to make all the decisions B) A client who relies on information from the local hospital for his or her health needs C) A client who does not make any decisions without his or her spouse's input D) A client who takes an active role in all health decisions |
D
Locus of control (LOC) is a concept from social learning theory. People who exercise internal control are more likely than others to take the initiative on their own health care and to be more knowledgeable about their health. They are also more likely to adhere to prescribed health care regimens such as taking medication, making and keeping appointments with physicians, maintaining diets, and giving up smoking. People who believe their health is largely controlled by outside forces (chance or others) are referred to as externals. |
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A client with diabetes wants to have better control over her blood sugar levels. She has set a goal that she will have laboratory values that reflect this, and she has been monitoring her blood sugar twice a day for the past month. Along with regular checks, she has kept all appointments with her nutritionist. This client is modeling which of the following?
A) Action stage B) Maintenance stage C) Termination stage D) Contemplation stage |
A
The action stage occurs when the person actively implements behavioral and cognitive strategies to interrupt previous behavior patterns and adopt new ones. This stage requires the greatest commitment of time and energy and is where the person is actually doing something to change the behavior. The termination stage occurs when the individual has complete confidence that the problem is no longer a temptation or a threat. The maintenance stage is where the person integrates adopted behavior patterns into his or her lifestyle. This stage lasts until the person no longer has temptation to return to previous unhealthy behaviors. In the contemplation stage, the person acknowledges having a problem, seriously considers changing a specific behavior, actively gathers information, and verbalizes plans to change the behavior in the near future. |
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Based on the concept that health is a highly individual perception, which of the following individuals would consider himself/herself healthy?
A) A senior citizen who has high blood pressure and refuses to leave home B) An honors college student who has multiple sclerosis and uses a wheelchair for mobility C) A college student who is seen in the student clinic for minor complaints at least once a week D) A homeless person who walks several miles each day looking for food |
B
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A client states that her cancer is the result of punishment from God for her sins. This client will most likely be:
A) Interested in alternative therapies for her cancer B) A passive recipient of health care C) An aggressive advocate for health care care D) A active participating recipient of health care |
B
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A nurse is working with various cultures while implementing health promotion activities for the community center. Bringing the minister of the church into the planning stage of these activities would be sensitive to which of the following cultural groups?
A) Latino American B) African American C) Asian American D) Native American |
B
In the African American community, the family and church have been major providers of social support. Latino Americans and Asian Americans view the family as being a major social support system. The Native American people live in social networks that foster mutual assistance and support. |
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A nurse is conducting a community assessment to determine which diseases are prevalent and most likely to occur. The nurse is basing the assessment on which model of health?
A) Adaptive B) Ecological C) Role performance D) Eudemonistic |
B
The ecological modelalso called the agent-host-environment model of health and illnessis used primarily in predicting illness rather than promoting wellness. Identification of risk factors results from interactions between agent, host, and environment, and is helpful in promoting and maintaining health. The role performance model defines health according to how individuals are able to fulfill their roles or perform their work. The eudemonistic model incorporates a comprehensive view of health, which is seen as a condition of actualization or realization of a person's potential. The adaptive model defines health as a creative process and disease as a maladaptation. The aim of treatment is restoration of the person's ability to cope. |
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A client comes to the clinic seeking information regarding smoking cessation classes and ways to improve respiratory function. This client is modeling which behavior?
A) Health protection B) Tertiary prevention C) Primary prevention D) Health promotion |
A
Health protection or illness prevention is “behavior motivated by a desire to actively avoid illness, detect it early, or maintain functioning within the constraints of illness.” Expressing a desire to quit smoking would be modeling this behavior. The information we are given does not tell us if the client has pathology or not, but the client certainly has been exposed to a health hazard. Health promotion is behavior motivated by the desire to increase well-being and actualize human health potential. Primary prevention measures focus on health promotion, and tertiary prevention measures focus on restoration and rehabilitationthey are not behaviors. |
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A client has been working hard in rehab following a traumatic brain injury. She has a weak support system in that her family lives a far distance away, she has no children, and her co-workers are not involved. Which of the following behavior-specific cognitions will the nurse focus on to assist this client with success in the rehab course?
A) Interpersonal influences B) Perceived benefits of action C) Situational influences D) Perceived barriers to action |
A
Interpersonal influences are a person’s perceptions concerning the behaviors, beliefs, or attitudes of others. Family, peers, and health professionals are sources of interpersonal influences that can affect a person’s health-promoting behaviors. Since this particular client does not have a close support system, the nurse will look to other possibilities (i.e., the other health professionals involved in the client’s care such as other nurses, therapists, and physicians). Situational influences are direct and indirect influences on health-promoting behaviors and include perceptions of available options, demand characteristics, and the aesthetic features of the environment. Perceived benefits of action affect the person’s plan to participate in health-promoting behaviors and may facilitate continued practice. Perceived barriers to action may be real or imagined and may affect health-promoting behaviors by decreasing the individual’s commitment to a plan of action. |
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A client is attending classes on building positive relationships with significant others as well as learning skills to be open-minded and respectful to those whose opinions are different. This client is focusing on which component of wellness?
A) Emotional B) Environment C) Social D) Physical |
C
The social component of wellness focuses on the ability to interact successfully with people and within the environment of which each person is a part, to develop and maintain intimacy with significant others, and to develop respect and tolerance for those with different opinions and beliefs. The physical component of wellness is the ability to carry out daily tasks, achieve fitness of all body systems, and practice positive lifestyle habits. The emotional component deals with the ability to manage stress and express emotions appropriately. The environmental component focuses on the health measures that improve the standard of living and quality of life in the community. |
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A nurse is working in a rehabilitation center with a client who had a serious injury. Part of the client's care plan includes working on coping with her current limitations since the injury. This nurse is working within which of the following models of health?
A) Adaptive B) Eudemonistic C) Role performance D) Clinical |
A
In the adaptive model, health is a creative process; disease is a failure in adaptation or maladaptation. The aim of treatment is to restore the ability of the person to adapt and cope, as in a rehabilitation setting. The role performance model defines health in terms of the individual's ability to fulfill societal roles or to perform work. According to this model, people who fulfill their roles are healthy, even though they may have an illness. The eudemonistic model incorporates a comprehensive view of health, which is seen as a condition of actualization or realization of a person's potential. The clinical model is a narrow interpretation of health, which is defined by the absence of disease. |
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A 76-year-old client with diabetes has had an above-the-knee amputation and is almost ready to return home from the hospital. The client lives alone. What is the best way to help the client adjust to the change in his health status?
A) Talk with the client about self-care measures and adaptive equipment for home use. B) Advise the client he should not live alone, because of his disability. C) Tell the client's family he should be in a nursing home. |
A
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A nurse is practicing the concept of holism to the client. Which of the following is the best example of this?
A) The nurse considers how the loss of a client's job will affect the regulation of the client's diabetes. B) The nurse is able to prioritize the needs of the client assigned according to Maslow's hierarchy. C) The nurse is careful to follow physician treatments on schedule. D) The nurse makes sure to do complete teaching regarding pharmacological interventions. |
A
The concept of holism emphasizes that nurses must keep the whole person in mind and strive to understand how one area of concern relates to the whole person. In this situation, the stress from a job loss will affect the person’s chronic condition. The nurse must also consider the relationship of the individual to the external environment and to others. The rest of the options are only focused on the physiology of the person’s condition, not the rest of the situation. |
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A nurse is assessing a client who practices yoga for relaxation, is following a nutritionally sound diet, and has supportive, sound relationships with her spouse and children. According to Dunn's high-level wellness grid, this client would exemplify which of the following?
A) High-level wellness in a favorable environment B) Emergent high-level wellness in a favorable environment C) Protected health in a favorable environment D) Emergent high-level wellness in an unfavorable environment |
A
Dunn describes a health grid in which a health axis and an environmental axis intersect. The intersection of the two axes forms four quadrants of health and wellness. High-level wellness in a favorable environment involves biopsychosocial, spiritual, and economic resources that support healthy lifestyles. Emergent high-level wellness and protected health are not part of Dunn's four quadrants of health and wellness. Emergent high-level wellness in an unfavorable environment would be exemplified by a client who has the knowledge to implement healthy lifestyles, but does not implement them because of family responsibilities, job demands, or other factors. |
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A client is having difficulty with feelings of self-loathing and disgust after being attacked and raped. According to Maslow’s human needs theory, which level is the client struggling with?
A) Love and belonging B) Physiological C) Safety and security D) Self-esteem |
D
Self-esteem and esteem from others includes feelings of independence, competence, self-respect, recognition, respect, and appreciation. Self-hatred and disgust is opposite of what one would expect in the self-esteem level of Maslow’s model. Physiological needs include air, food, water, rest, and sleep. Safety and security needs are those things, both psychological and physiological, that help the person feel safe. Love and belonging needs include giving and receiving affection, attaining a place in a group, and maintaining the feeling of belonging. |
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Mrs. Parajh, a newly diagnosed diabetic, has taken her medications and testing her blood sugar as instructed. She is confident that she can also improve her blood sugar control with diet and exercise, and recently went to the HMO education center to check out a video on the management of diabetes. Her actions are most representative of which of the following models:
A) Health Belief Model B) Clinical Model C) Role Performance Model D) Agent-Host-Environment Model |
A
Correct, While Mrs. Parajh probably has beliefs about the seriousness of her illness, which are influencing her actions, the health belief model is most useful to determine who is likely to participate in health-promoting activities. She is already taking action. The clinical model focuses on signs and symptoms of illness, which are not mentioned. The role performance model relates to the client's ability to act in her roles or work. The agent-host-environment model focuses on predicting illness. |
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The nurse has been working with the family of a client with cystic fibrosis since the child's diagnosis 6 years ago. Over this time, the client's mother has gained 50 pounds and has recently started taking prescription antidepressants. On the last visit, the mother said, "I just don't know how much longer we can go on." What nursing diagnosis should the nurse consider as an addition to the family's care plan?
A) BiPolar Disorder B) Caregiver Role Strain C) Transference Syndrome D) Fear of Failure |
B
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For which of the following client's would you take an apical pulse rather than a radial pulse?
A) A client in shock B) To check a client's response to changing from a lying to a sitting position C) A client with arrhythmia D) A client less than 24 hours postoperative |
C
Correct, if the cardiac rhythm is irregular, the apical pulse is the most accurate and informative. For clients in shock, use the carotid or femeroal pulse. The radial pulse is adequate for determining change in orthostatic heart rate and for routine postoperative vital sign checks for clients with regular pulses. |
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The nurse is unable to locate the client's popliteal pulse during a routine examination. What would be the appropriate next step?
A) Check for a pedal pulse B) Check for a femoral pulse C) Take the client's blood pressure on that thigh D) Ask another nurse to try to locate that pulse |
A
If a pedal pulse, which is more distal than the popliteal, is present, then adequate arterial circulation to the leg is present even though the popliteal artery has not been located. Presence of a femoral pulse would not provide confirmation that arterial flow exists below that point. Taking a thigh BP requires locating the popliteal pulse. Since the purpose of finding the popliteal pulse is to provide information about arterial circulation to the leg, checking the distal pulse before requesting assistance from another nurse is appropriate. |
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Which of the following might be the BEST way to measure medication adherence for a patient with diabetes?
A) Direct observation of dosing with insulin B) Evidence of illness complications or exacerbations C) Objective measurement of blood sugar and HgbAIC D) Questioning the patient about his or her medication routine |
A
Correct, Although not always practical, direct observation is the best method to measure adherence (for example, watching a heroin addict actually take the methadone dose). Adherence to treatment regimes does not always ensure the client will be without complications or that lab values will respond to proper medication administration. Client report or recall is not always accurate, even if the client believes he or she is telling the truth. |
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For a client with a previous blood pressure of 138/74 and a pulse of 64, approximately how long should the nurse take to release the blood pressure cuff in order to obtain an accurate reading?
A) 10-20 seconds B) 30-45 seconds C) 1-3.5 minutes D) 3-3.5 minutes |
B
Correct, if the cuff is inflated to about 30 mmHg over previous systolic pressure, that would be 168. To ensure that the diastolic has been determined, the cuff should be released slowly until the mid-60's mmHg (and then completely) for someone with a previous reading of 74. Thus, a range of 90 mmHg at a rate of 2 to 3 mm per second will require 30 - 45 seconds. |
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As part of preparing a client for a test, you are to take vital signs. However, the client is on the phone. How would you handle taking the client's respiratory rate?
A) Count the respirations during the time that the client is listening (rather than talking) on the phone B) Tell the client it is important to end the call now and resume it at a later time C) Wait at the client's bedside until the phone call is completed and then count respirations D) Record the measurement as "deferred" since the talking client is clearly not in respiratory distress and take it later. |
D
Correct, Postponing the assessment may seem a controversial answer to some nurses and is definitely a judgment requiring critical thinking. Unless the client is leaving for the test immediately and respiration rate is a critical aspect of the pretest assessment, it is probably not necessary to invade privacy and require the patient to end the phone call nor to waste the nurse's time waiting at the bedside for the call to be completed. Because respirations should be counted "with the patient at rest", counting during a pause in the conversation doesn't really qualify. Agency policy would dictate if the defferal should be charted or just the accurate measurement once it has been obtained. |
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Although clients may exhibit calm behavior, physical evidence of stress may still be manifested by
A) constricted pupils B) Dialated peripheral blood vessels C) Hyperventilation D) Decreased heart rate |
C
With stress, respirations increase, pupils dialate, peripheral blood vessels constrict, and the heart rate increases. |
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At work, several long-term clients have recently died. Which of the following actions is most likely to represent ineffective coping?
A) The nurse talks at length to her partner about death B) The nurse keeps busy with other actions and doesn't think about the deaths for several days C) The nurse offers to work extra shifts for several weeks D) Several nurses schedule a group session with the agency clergy to discuss the deaths |
C
Effective coping may include verbalizing feelings (one-to-one or in groups) or distraction. However, taking on additional work would only serve as an additional stressor. In addition, the nurse who has not begun resolution of these feelings is unlikely to be able to meet client's emotional needs. |
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When you take your cleint's temperature at 8:00 am using an oral electronic thermometer, the result is 36.1o C (92.2 o F). All other vital signs are within normal range. What would you do next?
A) Wait 15 minutes and retake it B) Check what the cleint's temperature was the last time C) Retake it with a different thermometer D) Chart the temperature, it is normal |
B
Correct, The temperature is pretty low, even for the morning. It would be best to see what the client's "usual" temperature has been. Maybe he or she usually has a low temperature. Depending on that finding, you might want to retake it with another thermometer to see if yours is functioning correctly. If everything checks out, chart it and check that the client has no signs of hypothermia. (remember, the question what "what would you do next") |
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The nurse is preparing for morning rounds. Which of the following may not be delegated to the nursing assistant?
A) Ambulate surgical clients B) Vital signs C) Fill water pitchers D) Skull and face assessment |
D
Assessment of the skull and face may not be delegated to unlicensed assistive personnel. |
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The nurse is caring for a 9-year-old client who was sexually abused by a minister. The child's parents are angry and confused as to why someone who was sexually attracted to children would choose to go into the ministry. The nurse explains that displacement of sexual drives into socially acceptable activities is a defense mechanism known as which of the following?
A) Repression B) Undoing C) Substitution D) Sublimation |
D
Sublimation is displacement of sexual drives into more socially acceptable activities. Repression is an unconscious mechanism by which threatening thoughts and feelings are kept from becoming conscious. Substitution is a mechanism in which highly valued, unacceptable, or unavailable objects are replaced by less valuable, acceptable, or available objects. Undoing is an action or words designed to cancel out some disapproved thoughts, impulses, or acts or in which the person acts to make reparation for a wrong. |
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Which condition would lead the RN to choose the dorsalis pedis pulse as the site for further assessing the client's status?
A) Irregular radial pulse B) Toes cool to touch C) Decreased urine output D) Altered level of consciousness |
B
The dorsalis pedis pulse site is in the foot, so this is the ideal site to assess the pulse for toes that are cool to touch. Decreased urine output, irregular radial pulse, and altered level of consciousness would best be assessed at the source of the origin, which is the apical pulse. |
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The nurse is performing a health assessment and notes a yellow tinge to the sclera of the eye. The nurse would document this as which of the following?
A) Jaundice B) Cyanosis C) Pallor D) Erythema |
A
Jaundice is a yellow tinge that is abnormal and is often noticed in the sclera of the eye. |
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The newly licensed nurse feels overwhelmed by the demands of working on a busy acute care unit and maintaining a growing family. What strategy should this nurse employ to lessen this stress?
A) Differentiate between "have to do" and "nice to do" at work. B) Focus on work instead of on family until more familiar with the environment. C) Spend the lunch hour completing documentation while eating a sandwich. D) Set the alarm earlier in order to get to work early. |
A
In order to manage stress the nurse must pay close attention to good nutrition, adequate sleep, and exercise. The nurse must also relax by spending time with family. This nurse should differentiate between what is essential care at work, and what is nice to do but can be eliminated on days when stress is high and resources are limited. |
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While attempting to choose a nursing diagnosis, the nurse must decide whether the client is experiencing anxiety or fear. What key point would help the nurse make this decision?
A) Anxiety is generally based in reality, fear is not. B) Anxiety is a milder form of fear. C) The source of fear is identifiable, but anxiety may be vague. D) Fear results in a physiologic response, while anxiety is psychologic. |
C
The source of fear is identifiable, but anxiety is vague. Fear and anxiety can both be based in reality or may not be based in reality. Both fear and anxiety can have physiologic and psychologic components. Fear and anxiety are different, so anxiety is not just a milder form of fear. |
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Which of the following positions does the RN assist the client in to best assess respiratory status?
A) Side-lying B) Supine C) Prone D) Semi-Fowler's |
D
Persons in a semi-Fowler's position will better aid themselves and the nurse to assess their respiratory status. Other positions such as prone, side-lying, and supine increase the volume of blood inside the thoracic cavity and compress the chest, compromising the client's respirations. |
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Which of the following is an appropriate nursing intervention for lowering a client's elevated temperature?
A) Lower room temperature. B) Give the client an antipyretic. C) Increase fluid intake. D) Bathe the client with ice water. |
C
Elevated body temperature contributes to dehydration, which leads to body tissues drying out and malfunctioning. Rehydrating the client's tissues will allow the temperature to return to normal. Giving a client an antipyretic requires a doctor's order. Bathing the client in ice water and setting the air conditioner to a lower temperature would lower the client's temperature too fast, possibly causing hypothermia. |
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The physician has just told the client that the results of a biopsy performed yesterday reveal no malignancy. During discharge teaching the nurse finds the client to be easily distractible and unable to focus. What is the nurse's best interpretation of this situation?
A) The client did not understand that there is no malignancy. B) These findings reflect mild anxiety, but the client should retain information taught despite this distractibility. C) Since there is no malignancy present, the client feels there is no need for teaching. D) Anxiety can result from both positive and negative stimuli. |
D
Anxiety can be the result of both positive and negative stimuli. There is no indication that the client doesn't understand the report or that the client discounts the need for teaching. The amount of information retained may be drastically reduced by this level of anxiety, so the nurse should take extra pains to ascertain if the client understands the teaching. |
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A client in a motor vehicle crash has arrived at the trauma unit in respiratory distress and unconscious. Knowing that chemoreceptors respond to changes in the concentrations of oxygen, carbon dioxide, and hydrogen, which of the following circumstances would account for this client's decrease in respiratory rate?
A) Increased environmental temperature B) Exercise C) Stress D) Increased intracranial pressure |
D
Factors that decrease respirations are decreased environmental temperature, certain medications, and increased intracranial pressure. Exercise, stress, and increased environmental temperature increase respiration rates. |
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Which of the following sites would be the most appropriate choice to use to measure a client's temperature who has a history of heart disease and has just eaten a bowl of vegetable soup?
A) Oral (after waiting 30 minutes) B) Rectal C) Popliteal D) Axilla |
A
Body temperature is frequently measured orally even if the client has eaten or drank something cold or hot. One only needs to wait 30 minutes, and then this site can be used. Rectal would be contraindicated in this client given the history of heart disease; the nurse would not want to risk stimulating the vagus nerve. Axilla is the preferred site for newborns, not adults. The popliteal site would not be used given the history of heart disease. There could be circulatory issues that might affect accurate reading since this site is much farther away from the heart. |
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A client has been admitted to the hospital with severe chest pain and has been medically diagnosed with myocardial infarction. The client tells the nurse, "I don't think this is my heart. That spaghetti I ate for lunch tasted a little strange. I think I have food poisoning." What defense mechanism is this client exhibiting?
A) Identification B) Denial C) Compensation D) Displacement |
B
Denial is an attempt to ignore unacceptable realities by refusing to acknowledge them. Compensation is covering up weaknesses by emphasizing a strength or by overachievement. Displacement is transferring emotional reactions from one object or person to another object or person. Identification is an attempt to manage anxiety by imitating the behavior of someone feared or respected. |
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The client tells the nurse that she does not wish to see her mother-in-law during this hospitalization because she does not like her. When the client's husband and her mother-in-law visit, the client is very cordial and acts happy to see both visitors. The nurse recognizes that this client may be using which defense mechanism?
A) Reparation B) Rationalization C) Regression D) Reaction formation |
D
Reaction formation is a mechanism that causes people to act exactly opposite to the way they feel. Rationalization is justification of behaviors by faulty logic and by ascribing socially acceptable motives to the behavior. Regression is resorting to an earlier, more comfortable level of functioning that is less demanding. Reparation is not a recognized defense mechanism. |
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The nurse is preparing to administer a cardiotonic drug to a client. Which of the following assessments should the nurse perform before administering the medication?
A) Popliteal pulse B) Respiratory rate C) Capillary blanch test D) Apical pulse |
D
The apical pulse should be assessed before administering any cardiotonic medication. |
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Which of the following determinants of blood pressure would explain a client's blood pressure reading of 120/100?
A) Blood volume B) Pumping action of the heart C) Peripheral vascular resistance D) Blood viscosity |
C
Peripheral vascular resistance especially affects diastolic blood pressure readings. A reading of 120/100 would be indicative of peripheral vascular resistance. A diastolic reading of 100 is too high when a normal reading is 80. Determinants of blood pressure such as blood volume, blood viscosity, and pumping action of the heart mainly affect the systolic reading portion of the blood pressure. |
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The nurse is assessing a female's breasts. The nurse finds both breasts rounded, slightly unequal in size, skin smooth and intact, and nipples without discharge. What is the nurse's next action?
A) Notify the physician. B) Document the findings in the nurse's notes as abnormal. C) Document the findings in the nurse's notes as normal. D) Notify the charge nurse. |
C
The findings are all normal, so the nurse would document the assessment in the nurse's notes as normal. |
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The nurse is preparing to perform a health assessment of the abdomen. Which of the following is the correct order to perform the assessment?
A) Inspect, auscultate, palpate, percuss B) Auscultate, percuss, palpate, inspect C) Palpate, percuss, auscultate, inspect D) Inspect, auscultate, percuss, palpate |
D
Palpation should always be performed last when performing an abdominal health assessment. Auscultation is done before palpation and percussion because palpation and percussion cause movement or stimulation of the bowel, which can increase bowel motility and thus heighten bowel sounds, creating false results. |
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During a health clinic assessment, the client describes his life as "in crisis." He reports that he has just been fired from his job, his wife has told him she wants a divorce, and he has been sick with a respiratory illness for 1 month. What statement, made by the nurse, reveals understanding of the care of a client in crisis?
A) "Experiencing a crisis is never positive, so we must work to relieve your anxiety as soon as possible." B) "Once you reach the crisis state, you may remain there for several months until you recover." C) "People generally find it easier to work through a crisis if someone is working with them." D) "Men often handle crisis better individually, while women do better with a counselor." |
C
In general, people are more successful in working through a crisis if they have someone to help them. This need for help is not gender dependent. A crisis results in such a state of disequilibrium that it is generally self-limiting and not a long-term event. Experiencing a crisis may actually offer the family or individual a potential for growth and change. |
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When assessing a client's peripheral pulse, the health care provider is also assessing which of the following?
A) Sound B) Depth C) Stress D) Rhythm |
D
When assessing peripheral pulses, one of the characteristics being assessed is rhythm along with rate, volume, and equality. Heart sounds are assessed with the apical pulse. Depth is a term used when assessing edema. Stress will affect the rate of both pulse and respiration, but it is not a characteristic of pulse assessment. |
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The nurse is assessing peripheral pulses on a client with suspected peripheral vascular disease. Which of the following should the nurse report to the physician immediately?
A) Pulses equal bilaterally B) Pulses present bilaterally C) Full pulsations D) Thready pulses |
D
Thready, weak, or decreased pulses are abnormal and should be reported to the physician. |
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Which of the following factors can affect oxygen saturation readings?
A) Activity B) Nutrition C) Skin color D) Environmental conditions |
D
Factors affecting oxygen saturation readings are hemoglobin, circulation, and activity. If there is shivering or excessive movement of the sensor site, this will interfere with an accurate reading. Environmental conditions, nutrition, and skin color are not factors. |
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A client is being treated for congestive heart failure. Which of the following physical findings would lead the RN to believe the client's condition has not improved?
A) Pulse oximetry reading of 96% B) Moderate amount of clear thin mucus C) Temperature of 98.6°F (37°C) D) Wheezing of breath sounds in all lobes |
D
Wheezing heard when assessing breath sounds is indicative of abnormal breath sounds, which are characteristic in congestive heart failure. A temperature reading of 98.6°F, moderate clear mucus, and a pulse oximetry reading of 96% are all normal findings and not an indication of heart failure. |
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Select the letter corresponding to the point of maximal impulse (PMI) where the stethoscope is placed to assess the apical pulse.
A) A) Aortic B) B) Pulmonic C) C) Tricuspid D) D) Mitral |
D
The answer is mitral. |
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An apical-radial pulse is determined by the RN to be the procedure to use on a client with cardiovascular disorders. Which of the following rationales did the RN use to make this decision?
A) Both arteriole and venous sounds were heard simultaneously. B) The pulse was bounding and easily obliterated. C) A forceful radial pulse is much too difficult to count correctly. D) The thrust of blood from the heart is too feeble for the wave to be felt at the peripheral pulse site. |
B
Knowing there is a history of cardiovascular disorders would alert the RN to the importance of the utmost accuracy for the client's pulse assessment. The apical-radial pulse is used to assess this type of client due to the feebleness of the wave of blood flow felt at the peripheral sites. A forceful radial pulse would be ideal for assessing a client's peripheral pulse, and a bounding pulse is not easily obliterated. Arteriole and venous sounds would be detected when using the Doppler, but there is no indication for Doppler use given this situation. |
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The nurse is caring for a client who was admitted to the intensive care unit to rule out myocardial infarction. The client is upset because he is restricted to the unit and is not allowed to smoke cigarettes. This morning the client became so angry that he threw his breakfast tray at the nurse. How should the nurse respond to this outburst?
A) Apologize to the client for the unit rules, but tell him the rules must be followed. B) Tell the client that it is understandable that he is upset, but the no smoking rule is not negotiable. C) Tell the client that he is acting like a child and that such behavior will not be tolerated. D) Call the charge nurse and refuse to take care of this client until he is under control. |
B
Telling the client that it is understandable that he is upset serves to show that the nurse accepts his right to be angry, but that the anger is the client's. The nurse should not assume responsibility for the anger by apologizing. Admonishing the client by saying that he is acting like a child is not professional and will most likely serve to destroy any hope of resolving this issue. The nurse cannot refuse to care for the client once the assignment has been accepted, since this may constitute client abandonment. |
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Which of the following arteries is most commonly used to obtain a blood pressure reading?
A) Femoral B) Ulnar C) Radial D) Brachial |
D
The brachial is the most common artery used to assess a blood pressure reading because it is the most accessible. The radial and ulnar could be used but they are not as accurate. The femoral is not as accessible as the brachial. |
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The client who has been experiencing slight anxiety is now communicating in a manner that makes it difficult for the nurse to understand the client's needs. When discussing this client with the physician, the nurse indicates the opinion that the client has progressed to which level of anxiety?
A) Moderate B) Severe C) Panic D) Mild |
B
Changes in verbalization can be indicative of increasing anxiety. Mild anxiety causes an increase in questioning. Moderate anxiety results in voice tremors and pitch changes. At severe levels, communication is difficult to understand. Communication may not be understandable at all when the client reaches the panic stage. |
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The nurse is performing a musculoskeletal assessment on a client admitted with a possible stroke. When testing for muscle grip strength, the nurse should ask the client to:
A) Grasp the nurse's index and middle fingers while the nurse tries to pull the fingers out. B) Shrug the shoulders against the resistance of the nurse's hands. C) Hold an arm up and resist while the nurse tries to push it down. D) Flex each arm and then try to extend it against the nurse's attempt to keep the arm in flexion. |
A
Although all options are included in testing muscle strength, only option A is testing muscle grip strength. |
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The nursing student admits to being mildly anxious about an upcoming examination. What is the likely result of this level of anxiety?
A) The student cannot talk about the examination without crying. B) The student's attention is focused solely on studying for the examination. C) The student's perception and learning is enhanced. D) The student's only topic of conversation is the examination. |
C
With mild anxiety, the student's perception and learning will be enhanced. Focusing only on studying for the examination would indicate a moderate anxiety level. Severe anxiety is the level at which the examination would consume all of the student's energy. Panic is the state in which the student might lose control of emotions regarding the examination. |
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The nurse is preparing the morning assignments. Which of the following assessments could the nurse delegate to the nursing assistant?
A) Vital signs assessment B) Neurological assessment C) Female genital assessment D) Musculoskeletal assessment |
A
Of the four options, the nursing assistant can only assess vital signs. |
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The following vital signs were taken and given to the RN by the UAP: 97.2-68-18-130/70. The client from whom these vital signs were obtained is a 75-year-old male. Which of the following rationales would explain this client's low temperature?
A) Hormones have fluctuated in this client. B) Anxiety level of the client has increased. C) Muscle activity has increased during the client's therapy session. D) Loss of subcutaneous fat is noted. |
D
This client is 75 years old, and research shows that older people are at risk for hypothermia. When one ages, subcutaneous fat is lost. If a client is anxious or stressed, this response stimulates the sympathetic nervous system. This in turn increases the production of epinephrine and norepinephrine, which increases metabolic and heat production, causing the temperature to rise. Women experience more hormonal fluctuations than men, and this is usually true with the secretion of progesterone at the time of ovulation. Since this client is a male, this is not a factor. Exercise, which represents hard work or strenuous activity, increases body temperature. That is not the case with this client. No reference has been made to a therapy session, and the temperature is decreased. |
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Which of the following sounds will be heard during phase 2 of Korotkoff's sounds?
A) A murmur or swishing sound B) Increased intensity of sound C) Disappearance of sound D) Faint, clear tapping sound |
A
Phase 1 of Korotkoff's sounds starts with a faint, clear tapping sound. Phase 2 produces a murmur sound. Phase 3 is marked by an increased intensity of sound. Phase 4 produces a muffled sound. Phase 5, the final phase, is where the sound disappears. |
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The nurse is caring for a critically ill child. While the nurse is preparing to administer a treatment to the child, the child's mother becomes distraught and begins to cry loudly while stroking the child's face. What is the nurse's best response to this occurrence?
A) Tell the mother that she needs to control herself for the benefit of her child. B) Explain the procedure that will occur with the treatment. C) Take the mother out of the room and comfort her. D) Distract the mother by having her straighten the linens on the bed. |
C
In this situation, the nurse must analyze which of the available options would be best for this mother and child. At this level of emotion, the nurse should remove the mother from the room and comfort her. While the mother's expression of anxiety is understandable, the child should be protected from this strongly upsetting situation. Just telling the mother to control herself discounts the seriousness of her anxiety and may serve to alienate the mother from the nurse. This mother is too upset to distract by smoothing linens. Explaining the procedure may help, but the mother should be removed at least temporarily and be comforted so that she will be able to receive the information. |
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Assessment of mental status reveals the client's general cerebral function. These include which of the following?
A) Cognitive and affective functions B) Affective and memory functions C) Affective and knowledge functions D) Cognitive and effective functions |
A
Cognitive (intellectual) and affective (emotional) functions are assessed. |
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The nurse is performing a lung assessment on a client with suspected pneumonia. Which of the following assessments should the nurse report to the physician immediately?
A) Breath sounds equal bilaterally B) Chest symmetrical C) Asymmetric chest expansion D) Bilateral symmetric vocal fremitus |
C
Chest expansion should be symmetrical. |
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The nurse manager of a busy emergency department is concerned about burnout in the nursing staff. The manager has overheard nurses complaining about their job, absenteeism has increased, and the nurses look tired and anxious. What action, planned by the nurse manager, would best serve to alleviate this burnout?
A) Assign each nurse to spend 30 minutes with the hospital psychologist daily. B) Ask administration to require 30 minutes of exercise at the end of each shift. C) Make certain that the nurses are well prepared for their responsibilities. D) Ask the physician staff to take over some of the tasks they routinely ask the nurses to do. |
C
In this situation, the best alternative is to be certain that the nurses are well prepared for the responsibilities of their jobs, as the frustration of being unprepared leads to burnout. Asking physicians to assume nursing tasks is not appropriate. Neither the nurse manager nor the administration can require counseling or exercise programs, particularly after work hours. Instituting such requirements would likely increase stress, frustration, and burnout. |
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The nurse elects to use a scale of stressful life events to assess the level of a newly admitted client's stress. How should the nurse explain the use of this scale to the client?
A) "We will consider only the negative life events that have happened to you recently." B) "This scale will give us some idea about your stress related to both positive and negative recent events in your life." C) "This scale will give us a definite stress level number that can be used to compare your stress to others your age." D) "You should try to remember any stressful event that has occurred to you in the last 10 years to include in the scale." |
B
Stress scales are useful to give the client and others an idea of the amount of stress that both positive and negative recent life events have placed on the client. The scales do take into consideration both positive and negative events and focus on events that have taken place recently. The scales are only an idea of stress level because each individual reacts to stressful events differently. |
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The nurse is preparing to assess a client's reflexes. Which of the following equipment should the nurse gather before entering the room?
A) Sterile gloves B) Clean gloves C) Penlight D) Percussion hammer |
D
A percussion hammer is used to test reflexes. |
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The nurse is preparing a client for an abdominal examination. Which of the following should be performed before the examination?
A) Assess vital signs. B) Ask client to urinate. C) Assess heart rate. D) Ask client to drink 8 ounces of water. |
B
The nurse should ask the client to urinate since an empty bladder makes the assessment more comfortable. |
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The nurse is caring for a client following a cerebrovascular accident (stroke). The client is able to comprehend what is being said to him; however, he is unable to respond by speech or writing. What is this form of aphasia called?
A) Acoustic aphasia B) Sensory aphasia C) Expressive aphasia D) Auditory aphasia |
C
Motor or expressive aphasia involves loss of the power to express oneself by writing, making signs, or speaking. Clients may find that even though they can recall words, they have lost the ability to combine speech sounds into words. |
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The nurse identifies that a client has not met the expected outcome established for the nursing diagnosis Ineffective Individual Coping. What nursing action is priority?
A) Rewrite the interventions used to address the problem. B) Explore reasons why the outcome was not achieved. C) Revise the nursing diagnosis. D) Reassess the patient, looking for previously unknown stressors. |
B
When the expected outcome is not met, the nurse, client, and support persons must explore reasons why before modifying the remaining portions of the care plan. |
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A client has returned to the nursing unit from having a cardiac catheterization. The RN is assessing the client's right pedal pulse (dorsalis pedis) and assesses no pulse present. On further investigation, the extremity is found to be warm and pink, and nail beds blanch well with 2 to 3 seconds capillary refilling time. How would the RN explain these findings?
A) The RN's watch has stopped working. B) A change in the client's health status has occurred. C) Too much pressure was applied over the pulse site. D) The client has thrown a blood clot in that extremity. |
C
Too firm of pressure on a pulse site will obliterate that pulse since assessing the dorsalis pedis pulse requires one to apply some pressure over the dorsalis pedis artery, making contact with the cones in the foot. The information provided gives no indication that any health change has occurred. A complication of a cardiac catheterization is a blood clot, but the assessment data given (warm, pink, etc.) are not symptoms of a blood clot. There are no data given in regard to equipment malfunction like a watch. |
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In the palpatory method of blood pressure determination, instead of listening for the blood flow sounds, light to moderate pressure is used over the artery as the pressure in the cuff is released. When is the pressure read from the sphygmomanometer?
A) When the second pulsation is felt B) When the cuff is applied C) When the first pulsation is felt D) When the cuff is being deflated |
C
The first pulsation that is felt after the cuff is slowly deflated is the blood pressure reading that is recorded if the palpatory method is used to assess a client's blood pressure. Assessing the pulse before the cuff is applied is not the pressure. When inflating the cuff, no pressure is felt. If the second pulsation is recorded, that would be an inaccurate reading. |
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The client has just received news of the death of a relative. Over the next few hours, what physiologic response would the nurse attribute to the shock phase of the alarm reaction caused by the stress of this event?
A) Some decrease in oxygen saturation B) Slight increase in urine output C) Drop in blood pressure from 130/80 to 120/75 D) A more bounding pulse |
D
During this shock phase the sympathetic nervous system is stimulated, resulting in increased myocardial contractility which would be reflected in the client as a bounding pulse. Blood pressure rises in response to angiotensin production. Norepinephrine release decreases blood flow to the kidney, which could make urine output decrease. The bronchial tree dilates, allowing more oxygen intake that would result in increased oxygen saturation. |
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The nurse is assisting the physician who is preparing to test a sexually active female client for cervical cancer. The nurse would expect the physician to perform which of the following?
A) Pap test B) Abdominal exam C) Rectal exam D) Breast exam |
A
For sexually active adolescent and adult women, a Papanicolaou test (Pap test) is used to detect cancer of the cervix. |
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Which of the following nursing interventions would assure the RN of an accurate temperature reading for a client?
A) Wait at least 10 minutes before taking the temperature after a client has been smoking. B) Assess that the equipment used is working properly. C) Place the client in a position that is most comfortable for the health care provider. D) Take the temperature with a chemical disposable thermometer when the client is perspiring. |
B
If the equipment is not working properly, no accuracy will be obtained in the readings. The type of equipment or method that is chosen will dictate client position, not the position of the health care provider. In order to use a chemical disposable thermometer, the client's skin must be dry for the thermometer to adhere to the skin. The recommended time to wait to assess an oral temperature is 30 minutes after one smokes, not 10 minutes. |
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The victim of domestic abuse tells the nurse, "I know my spouse didn't mean to hurt me. The situation just got out of hand." The nurse recognizes that the client is exhibiting which of the following?
A) Introjection B) Minimization C) Projection D) Intellectualization |
B
Minimization is not acknowledging the significance of a behavior. Intellectualization is a defense mechanism in which an uncomfortable or painful reality is evaded by using a rational explanation that removes personal significance from the event. Introjection is a form of identification in which the person adopts another person's norms or values, even if those norms or values are contrary to what the person would have previously assumed. Projection is blaming another person or the environment for one's own unacceptable thoughts, shortcomings, or failures. |
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While performing an assessment of the integument system, the nurse notes the client's eyeballs are protruding and the upper eyelids are elevated. What term would the nurse use to document this finding?
A) Cyanosis B) Erythema C) Normocephalic D) Exophthalmos |
D
Hyperthyroidism can cause exophthalmos, a protrusion of the eyeballs with elevation of the upper eyelids, resulting in a startled or staring expression. |
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The RN assesses a client who is recovering from femoral popliteal bypass surgery and discovers that it is difficult to assess the dorsalis pedis pulses. Which of the following nursing interventions would be most appropriate for the nurse to use?
A) Obtain a Doppler ultrasound stethoscope. B) Ask another nurse to assess the pulses. C) Document the findings. D) Wait and just try again later. |
A
Obtaining a Doppler ultrasound stethoscope is the appropriate action to take. The Doppler will ensure accuracy by helping to exclude environmental sounds. If one nurse is having difficulty with the pulse and accuracy, getting another nurse is not going to be the best choice. Just documenting the findings does not address the problem of getting an accurate pulse reading. Waiting until later may be harmful to the client, creating an unsafe environment. |
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While performing a health assessment, in which position should the nurse place the client for inspection of the jugular veins?
A) 90-degree angle B) 60-degree angle C) 15-degree angle D) 30- to 45-degree angle |
D
The nurse should place the client in the semi-Fowler's postion (30- to 45-degree angle) while inspecting the jugular veins for distention. |
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How do the JCAHO 2006 National Patient Safety Goals improve the effectiveness of communication among caregivers?
A) Conduct a verification process to confirm the correct procedure. B) Use the client's room number as an identifier. C) Standardize a list of abbreviations that are not to be used throughout the organization. D) Annually review a list of look-alike/sound-alike drugs used in the organization. |
C
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Which of the following safety hazards would be taken into consideration in planning care for an elderly client?
A) Suffocation B) Burns C) Poisoning D) Drowning |
B
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The nurse suspects that the client has a hearing disorder; however, the client denies not being able to hear. What initial assessment technique should the nurse employ?
A) Confront the client with the nurse's suspicion. B) Observe the client's interaction with family. C) Schedule a Weber and Rinne test. D) Use an otoscope to visualize the inner ear. |
B
The most telling of these options would be to observe the client's interactions with family. The nurse should assess for frequent requests to repeat, inattention to conversation, turning one ear to the conversation, and lip-reading. The Weber and Rinne test and use of an otoscope may be a part of assessment, but will not yield as much information as this simple observation. The client has already denied a hearing problem, so confronting the client with the nurse's suspicion will probably only serve to alienate the client from the nurse. |
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An older client has become very confused since being hospitalized earlier in the week. Prior to this illness, the client exhibited clear thought processing and was able to maintain an independent lifestyle. How would the nurse document this mental state?
A) As reversible confusion B) As delirium C) As sundown syndrome D) As dementia |
B
Delirium is acute confusion caused by illness, medication, or a change in environment and is the appropriate documentation for this client. Dementia is chronic confusion with symptoms that are gradual in onset and are irreversible. The other options do not reflect proper documentation of this client's situation. |
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Which of the following nursing diagnoses would the nurse expect to find on the care plan of a client prone to falls?
A) Risk for Disuse Syndrome B) Risk for Injury C) Risk for Suffocation D) Deficient Knowledge |
B
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A major focus of professional nurses is preventive care. In providing preventive care the nurse should focus on:
A) Developing nursing diagnoses B) Health Education C) Research and Development D) Scientific knowledge |
B
Health Education is a major focus of preventive care. The goal of health education is to foster health-promoting and health-protective behaviors. |
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An 86-year-old client with Alzheimer's disease continually tries to get out of bed at night. Which alternative safety measure would the staff choose to use with this client?
A) Place a bed safety monitoring device on the bed. B) Use relaxation techniques. C) Orient the client to her surroundings. D) Explain all procedures and treatments. |
A
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Which of the following would the nurse identify as a safety hazard in the infant?
A) Suffocation in the crib B) Alcohol consumption C) Pedestrian accidents D) Drowning |
A
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When applying restraints on a client, the nurse would secure a doctor's order and:
A) Secure the restraint to the side rail. B) Assess the restraints every 10 minutes. C) Tie the restraint with a square knot. D) Pad bony prominences. |
D
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Which of the following safety hazards affects a developing fetus?
A) Banging into objects B) X-rays C) Bicycle rides D) Recreational activities |
B
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Which statement regarding the causes, consequences, or treatment of fever is false?
A) It is a protective response to pathogens B) Shivering results in increased heat production C) Increased perspiration may lead to dehydration D) Temperature is rapidly reduced to prevent seizures |
D
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Which of the following steps helps to promote a safe environment for the client?
A) Provide adequate lighting. B) Turn off alarms to reduce noise. C) Keep clutter to a minimum in the client's room. D) Have the client wear terry cloth slippers. |
A
Providing adequate lighting will help prevent the client from falling. The environment should be clutter-free because any clutter can cause the client to fall. Wearing terry cloth slippers would allow the client to fall. The client should have rubber skid-resistant soles. Noise should be kept to a minimum, but turning off alarms would endanger a client. |
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During review of admission data, the nurse learns that the new client has impairment of kinesthetic sensation. Which nursing intervention should be planned for this client?
A) Use only nonirritating soaps for bathing. B) Provide all teaching materials in very large font. C) Use the clock face as a format for describing the position of food on meal trays. D) Ensure that the client has assistance when ambulating. |
D
Kinesthetic sensation refers to the awareness of the position and movement of body parts. The client with impairment of this sensation may be prone to injury by falling and should be assisted when ambulating. There is nothing wrong with the client's eyesight or skin. |
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Which of the following charges could the nurse be brought up on if the nurse were to restrain a client against his or her will?
A) Defamation of character B) Slander C) Negligence D) Assault and battery |
D
Assault and battery is the charge that could be brought against a nurse who restrains a client against his will. Defamation of character is a spoken or written statement made maliciously and intentionally that may injure the client's reputation. Negligence is the failure of commission of an act or the omission of an act that a reasonably prudent person would have done in a similar situation that leads to harming another person. Slander is malicious or untrue spoken words about another person that are brought to the attention of others. |
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An older client has become very confused since being hospitalized earlier in the week. Prior to this illness, the client exhibited clear thought processing and was able to maintain an independent lifestyle. How would the nurse document this mental state?
A) As reversible confusion B) As delirium C) As sundown syndrome D) As dementia |
B
Delirium is acute confusion caused by illness, medication, or a change in environment and is the appropriate documentation for this client. Dementia is chronic confusion with symptoms that are gradual in onset and are irreversible. The other options do not reflect proper documentation of this client's situation. |
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Which of the following interventions is used to prevent falls in a healthcare agency?
A) Display the phone number tot he nurse's station. B) Keep electrical cords under the bed. C) Keep the environment tidy D) Read label directions |
C
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The client who has the medical diagnosis of Alzheimer's disease is confused and has difficulty interpreting environmental stimuli. Which nursing diagnosis problem statement most accurately describes this client's situation?
A) Acute Confusion B) Disturbed Sensory Perception C) Altered Role Performance D) Disturbed Thought Processes |
D
Since this client has dementia, which interferes with the ability to interpret stimuli, the correct diagnosis problem statement is Disturbed Thought Processes. Disturbed Sensory Perception is more useful with the client who has difficulty related to sensory input (perception). Clients with Alzheimer's disease are more likely to exhibit chronic confusion. There is no evidence to support Altered Role Performance. |
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The nurse is assessing a client who was just brought to the emergency department. The client can be aroused only with extreme or repeated stimuli. How should the nurse describe this client in a report to the ED physician?
A) Disoriented B) Comatose C) Somnolent D) Semicomatose |
D
Since this client can be aroused with extreme stimuli or repeated stimuli, the correct description is semicomatose. The comatose client is not arousable. The somnolent client is very drowsy, but will respond to stimuli. A disoriented client is alert, but not oriented to time, place, or person. |
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The nurse is caring for a client who has difficulty hearing conversation. What intervention should the nurse implement?
A) Overarticulate words. B) Vary the volume of voice through sentences. C) Face the client during conversation. D) Use short phrases. |
C
The best intervention is to face the client during conversation so that the client can employ any lip-reading skills. The nurse should use longer phrases that more completely explain concepts. Overarticulation of words makes them difficult to lip-read. The volume of voice should be consistent. |
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A patient develops a urinary tract infection while an indwelling urinary catheter is in place. This patient has a:
A) Nosocomial infection B) Passive infection C) Latent infection D) Super infection |
A
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Which statement about immunizations is true? They:
A) Provide artificial antibodies to protect against specific diseases B) Cause a mild case of the disease so that permanent immunity results C) Elicit immune responses against the antigen from which the vaccine was made D) Cause recognition of the antigen, which requires disease exposure before antibodies are synthesized |
C
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Which of the following would the nurse identify as a safety hazard in the infant?
A) Pedestrian accidents B) Drowning C) Alcohol consumption D) Suffocation in the crib |
D
Suffocation in the crib is a safety hazard for both newborns and infants. Drowning is seen in toddlers and preschoolers. Exposure to alcohol consumption is a safety hazard to the fetus, and pedestrian accidents are seen in the older adult. |
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The nurse is assisting a visually impaired client with ambulation. How should the nurse proceed with this intervention?
A) Walk slightly behind the client. B) Walk on the left side of the client. C) Walk on the right side of the client. D) Walk 1 foot in front of the client. |
D
The nurse should walk about 1 foot in front of the client, offering the client an arm. The side the nurse walks on will depend upon the preference of the client. |
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The nurse is planning care for a client who is experiencing dementia. What essential concept should the nurse consider for this planning?
A) Pain mediation will increase dementia. B) Activities should be scheduled at the same time each day. C) It is important to talk with the client throughout procedures. D) Background noise like music will keep this client calm. |
B
The client with dementia benefits from a routine schedule of activities. The client typically is better oriented when it is quiet. Pain should be controlled. Procedures should be explained in direct, clearly understandable terms, but the nurse should avoid "chatter." |
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Which of the following are methods of assessing clients at risk for injury? (Select all that apply.)
A) Cognitive awareness B) Mobility and health status C) Nursing history D) Physical examination |
C, D
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Bioterrorism has become another threat to homeland security. Keeping this threat in mind, which of the following agents is of highest concern?
A) Tuberculosis B) Smallpox C) Cancer D) Flu |
B
Smallpox, anthrax, botulism, plague, viral hemorrhagic fevers, and tularemia are the agents that are of highest concern with bioterrorism. |
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The nurse is providing education for the parents of a 7-month-old child who has just been diagnosed with a hearing loss. What guidance should the nurse provide?
A) Interventions to support hearing are not useful until the child is at least 9 months old. B) Hearing loss is not serious until 1 year of age. C) Keep your child in a quiet environment until additional testing is done. D) Expect that your child will be enrolled in a special hearing intervention program immediately. |
D
The Centers for Disease Control and Prevention recommend that children with hearing loss be enrolled in an intervention program by 6 months of age. The child should be stimulated with color, smells, body positions, and textures to develop compensatory mechanisms for the hearing loss. Hearing loss is serious from birth. |
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The mother of a 2-year-old expresses concern to the nurse that her child continually climbs out of the crib at home. The nurse advises the mother that she should:
A) Omit the afternoon nap. B) Remove all objects from around the crib. C) Restrain the child if he gets up more than once. D) Place a crib net over the top of the crib. |
D
A crib net will prevent an active child from climbing out of the crib but will allow him freedom to move about in the crib. Just removing objects off the floor from around the crib would not prevent a child from climbing out of a crib. Restraining the child would be dangerous and contribute even more to his determination of getting out of the crib. A child of 2 years should still be taking a nap, and that poses a dangerous situation, naptime or bedtime, if the child is still crawling out of the crib. |
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Which of the following safety hazards would be taken into consideration in planning care for an elderly client?
A) Suffocation B) Poisoning C) Burns D) Drowning |
C
Falls, burns, and pedestrian and motor vehicle crashes are safety hazards in older adults. Drowning and poisoning are seen in the toddler age client, and suffocation is a hazard in newborns and infants. |
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Which of the following desired outcomes/goals would be appropriate for an elderly client in preventing injury?
A) The client will demonstrate an understanding of all limitations. B) The client will make uninformed choices when addressing health issues. C) The client will establish a buddy system. D) The client will take his medication as desired. |
C
Establishing a buddy system provides social contact, safeguards against abuse, and offers respite for caregivers. It also provides a way for elders to be checked up on daily. The client may resent limitations if he is imposed and act out in such a way to cause injury. Making uninformed choices about one's health could be unsafe instead of safe to the client. A routine should be established for medication administration with correct dosage to prevent the possibility of overdose toxicity. |
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The client has a long history of congestive heart failure and has been treated with large amounts of intravenous furosemide (Lasix). Based upon this history, for which sensory impairment would the nurse monitor this client?
A) Loss of ability to taste B) Loss of ability to smell C) Hearing loss D) Vision loss |
C
Furosemide (Lasix) can be ototoxic if taken over long periods of time. The nurse would monitor for hearing loss. |
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Which nursing activity reduces the risk for urinary tract infection in the patient with an indwelling urinary catheter?
A) Irrigating the catheter and bladder with a mild acidic solution at least once daily B) Securely anchoring the catheter to prevent movement in and out of the urethra C) Administering oral prophylactic urinary antiseptics D) Changing the urinary catheter every other day |
B
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The client is being treated in an intensive care unit for a complicated myocardial infarction. The client's family lives 150 miles away and is unable to visit. Is this client at greater risk for sensory overload or sensory deprivation?
A) Both B) Sensory Overload C) Sensory Deprivation D) Neither |
B
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A woman becomes ill after eating food served at a party. Which type of pathogenic transmission has occurred?
A) Droplet B) Direct contact C) Common vehicle D) Vector-borne |
C
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A client who has had a traumatic brain injury is physiologically stable but remains in a coma. Caregivers are participating in a coma stimulation program with this client. Which action is correct for this situation?
A) Provide continuous auditory stimulation through music tapes. B) Provide visual and tactile stimulation concurrently with auditory background. C) Ensure the client has sleep/rest periods alternating with sensory stimulation. D) Limit stimulation to a 5- to 10-minute session. |
C
These coma stimulation programs are a means of providing sensory stimulation to promote brain recovery. Stimulation should be delivered in a quiet environment, should be limited to 30- to 45-minute sessions, and should be done episodically throughout the day, not continuously. Periods of sleep/rest should be alternated with the sensory stimuli. |
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Which is the best protection against infection at home, in the hospital, or in the outpatient setting?
A) Thorough hand washing B) Avoidance of known carriers C) Prophylactic use of antibiotics D) Use of appropriate isolation procedures |
A
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How do the JCAHO 2007 National Patient Safety Goals improve the effectiveness of communication among caregivers?
A) Annually review a list of look-alike/sound-alike drugs used in the organization. B) Conduct a verification process to confirm the correct procedure. C) Standardize a list of abbreviations that are not to be used throughout the organization. D) Use the client's room number as an identifier. |
C
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A hospitalized elderly man suddenly does not recognize his daughter and complains that his wife has not visited him, even though she has been dead for 5 years. The client was clear of mind and thought prior to hospitalization. What NANDA nursing diagnosis problem statement would be used for this client?
A) Delirium B) Alzheimer's C) Acute Confusion D) Mental Regression |
C
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The client who had a traumatic brain injury last week is now persistently unconscious and is being cared for in the intensive care unit. The family asks when attempts to stimulate the client will begin. What is the nurse's best answer?
A) "There is little hope of improvement from persistently unconscious states." B) "Stimulation will not begin until transfer to a rehabilitation unit." C) "The stimulation process will begin when the client is physiologically stable." D) "Attempts begin while the client is still in the ICU." |
D
Current research indicates that stimulation efforts should begin immediately. The nurse should not discourage hope in this family. |
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Which correctly describes the sequence of events leading to an infection?
A) Causative agent, susceptibility of host, pathogen B) Susceptibility of host, pathogen, portal of entry, carrier C) Carrier, pathogen, portal of entry, susceptibility of host D) Pathogen, reservoir, portal of entry, susceptibility of host |
D
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The middle-aged client reports having diabetes mellitus since childhood. Today's blood glucose reading is 180. Because of this history, the nurse would monitor this client for which sensory disturbance?
A) Loss of ability to smell B) Hearing loss C) Vision loss D) Loss of ability to taste |
C
Uncontrolled diabetes mellitus is a leading cause of blindness in the United States. |
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When applying restraints on a client, the nurse would secure a doctor's order and:
A) Assess the restraints every 10 minutes. B) Secure the restraint to the side rail. C) Pad bony prominences. D) Tie the restraint with a square knot. |
C
Padding bony prominences will prevent possible skin breakdown. The limb with a restraint should be assessed frequently, but every 10 minutes is not necessary. At least every 32 minutes is appropriate. When a restraint is secured in place, a clove-hitch knot should be used, not a square knot. The clove-hitch knot will not tighten when pulled. Restraints are never tied to a side rail. The ends should be secured to the part of the bed that moves to elevate the head. |
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Which is the most common nosocomial infection occurring in hospitalized patients?
A) Wound B) Pneumonia C) Candidiasis D) Urinary tract |
D
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Which assessment findings would the nurse interpret as being possible signs of sensory overload in a hospitalized client? (Select all that apply.)
A) Sleeplessness B) Anxiety C) Apathy D) Racing thoughts E) Somatic complaints |
A, B, D
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The nurse suspects that the client has a hearing disorder; however, the client denies not being able to hear. What initial assessment technique should the nurse employ?
A) Confront the client with the nurse's suspicion. B) Observe the client's interaction with family. C) Schedule a Weber and Rinne test. D) Use an otoscope to visualize the inner ear. |
B
The most telling of these options would be to observe the client's interactions with family. The nurse should assess for frequent requests to repeat, inattention to conversation, turning one ear to the conversation, and lip-reading. The Weber and Rinne test and use of an otoscope may be a part of assessment, but will not yield as much information as this simple observation. The client has already denied a hearing problem, so confronting the client with the nurse's suspicion will probably only serve to alienate the client from the nurse. |
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Which of the following nursing interventions is appropriate when a client has a seizure?
A) Restrain the client. B) Insert a tongue blade into the client's mouth. C) Loosen any clothing around the neck and chest. D) Turn the client to the supine position if possible. |
C
Loosening any clothing around the neck and chest prevents constriction that might occur during the seizure that could compromise the airway. Research has found that more injury can occur to the client if the caregiver tries to place anything in the mouth during the seizure. A client should never be restrained during a seizure. The nurse should stay with the client and call for assistance, if needed. If possible, the client should be turned onto the lateral position, not supine, to allow for any secretions to drain out of the mouth. |
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An 86-year-old client with Alzheimer's disease continually tries to get out of bed at night. Which alternative safety measure would the staff choose to use with this client?
A) Place a bed safety monitoring device on the bed. B) Use relaxation techniques. C) Explain all procedures and treatments. D) Orient the client to her surroundings. |
A
Alzheimer's disease causes impaired intellectual functioning, so a safety device that is weight sensitive would alert the nurse when the client is trying to get out of bed. Explaining procedures, orienting to surroundings, and using relaxation techniques would not be appropriate alternatives to use with this client. |
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Which health care professionals have the greatest control over the level of sensory input in the hospital?
A) Nurses B) Planners C) Administrators D) Physicians |
A
Nurses have the greatest amount of control over the level of sensory input in the hospital. Nurses can decrease sensory overload by controlling lights, noise, odors, and pain. Nurses can also increase sensory input by stimulating the client as appropriate. Administrators, planners, and physicians are not at the bedside as much as nurses. |
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Which of the following interventions would help prevent falls in the elderly client?
A) Turn the light on after getting out of bed. B) Check vision every 5 years. C) Place socks on feet. D) Exercise regularly. |
D
The client needs to exercise regularly to maintain strength, flexibility, mobility, and balance, which prevents falls. Vision can be a cause of falls, but it should be checked at least once a year; every 5 years is not often enough. Elderly clients should have something on their feet when walking, but not socks that will allow them to fall. A nonskid-type sock or shoe will help prevent falls. The client should be able to turn the light on before getting out of bed as inadequate lighting is another cause for falls. |
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Which of the following safety hazards affects a developing fetus?
A) Recreational activities B) Bicycle rides C) Banging into objects D) X-rays |
D
Exposure to x-rays in the first trimester could cause harm to the developing fetus. Bicycle rides and recreational activities would be good for the developing fetus; the mother should stay as active as possible during the pregnancy. Physical activity promotes good health. Banging into objects is what a toddler would be likely to do, not an expectant mother. |
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Which of the following safety hazards affects a developing fetus?
A) Recreational activities B) Bicycle rides C) Banging into objects D) X-rays |
D
Exposure to x-rays in the first trimester could cause harm to the developing fetus. Bicycle rides and recreational activities would be good for the developing fetus; the mother should stay as active as possible during the pregnancy. Physical activity promotes good health. Banging into objects is what a toddler would be likely to do, not an expectant mother. |
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The nurse's major goal for a client who is at risk for injury is to:
A) Remain free from injury. B) Keep the client dependent on the staff for all care. C) Make all choices for the client. D) Assess the client's mental status. |
A
The nurse's major goal for a client who is at risk for injury is for the client to remain injury-free. The nurse will need to assess the client's mental status to help accomplish this goal. Keeping the client dependent on the staff for care and making all choices for the client does not encourage independence, which would contribute to the client's overall self-esteem. |
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How do the JCAHO 2006 National Patient Safety Goals improve the effectiveness of communication among caregivers?
A) Annually review a list of look-alike/sound-alike drugs used in the organization. B) Standardize a list of abbreviations that are not to be used throughout the organization. C) Conduct a verification process to confirm the correct procedure. D) Use the client's room number as an identifier. |
B
Standardizing a list of abbreviations, acronyms, and symbols that are not to be used throughout the organization is one of the ways the National Patient Safety Goals improve the effectiveness of communication among caregivers. Using the client's room number as an identifier is a passive technique that would improve the accuracy of client identification. Conducting a verification process to confirm that the correct procedure for the correct client is to be performed is another way to improve the accuracy of client identification. Annually reviewing a list of look-alike/sound-alike drugs is used to improve the safety of use of medication in an organization-not to improve effective communication. |
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Which of the following nursing diagnoses would the nurse expect to find on the care plan of a client prone to falls?
A) Risk for Disuse Syndrome B) Deficient Knowledge C) Risk for Injury D) Risk for Suffocation |
C
Risk for Injury is a state in which the individual is at risk as a result of environmental conditions like a fall. Deficient Knowledge deals with injury prevention. A client who is already prone to falls may not have the cognitive ability for a knowledge deficient. Risk for Disuse Syndrome is a deterioration of body system as the result of prescribed or unavoidable musculoskeletal inactivity. Risk for Suffocation is inadequate air available for inhalation. |
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Which of the following strategies would contribute to maintaining safety in the home?
A) Keep plants in the home. B) Always pull a plug at the plug-in from the wall outlet. C) Use overloaded outlets when necessary. D) Remove labels from containers and refill for recycling. |
B
Always pull a plug at the plug-in from the wall outlet. Pulling a plug by its cord can damage the cord and plug unit, creating a dangerous situation. Not knowing which plants are poisonous and which are not may pose a serious problem for children in the home. Always avoid overloading outlets at anytime because this a cause of fire. Do not remove container labels or reuse empty containers to store different substances. Laws mandate that the labels of all substances specify an antidote. |
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The odor from a hospitalized client's draining wound permeates the room and is very overwhelming and distracting to the client and the staff. What intervention would be most helpful?
A) Spray the room routinely with a floral room spray. B) Burn a candle in the room. C) Instill a vinegar solution into the wound. D) Keep the wound dressing dry and clean. |
D
The best way to keep odors controlled is to keep the wound dressing dry and clean. Spraying the room with a floral spray will add to the sensory overload. Burning a candle will also add to the sensory overload, and burning candles are not safe in the hospital environment. Vinegar is not instilled into wounds. |
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The client has had a cerebral vascular accident (CVA) and now cannot speak. It is unclear from assessment if the client understands spoken words. What NANDA nursing diagnosis problem statement would be used for this client?
A) Disturbed Sensory Perception: Auditory B) Hearing Impairment C) Disturbed Sensory Perception: Oral D) Muteness |
A
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While eating in a restaurant, a nurse notices that a customer at the next table begins to clutch his throat while eating a steak. Which of the following responses would the nurse perform first?
A) Start chest compressions. B) Ask the customer if he is choking. C) Perform the Heimlich maneuver. D) Attempt to give five back blows. |
B
The first step is to ask if the person is choking. If he indicates he is, the next step would be to perform the Heimlich maneuver. Five back blows are reserved for an infant who is choking. Chest compressions would be given if the person was unconscious; this client is not. He is clutching his throat. |
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The client has had a cerebral vascular accident (CVA) and now cannot speak. It is unclear from assessment if the client understands spoken words. What NANDA nursing diagnosis problem statement would be used for this client?
A) Optimal Sensory Perception: Visual B) Disturbed Sensory Perception: Auditory C) Disturbed Sensory Perception: Sensory Tactile D) Disturbed Sensory Perception: Visual |
B
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The nurse's major goal for a client who is at risk for injury is to:
A) Assess the client's mental status B) Keep the client dependent on the staff for all care C) Make all choices for the client D) Remain free from injury by assessing th environment for hazards |
D
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There is a very confused client on the unit and she is wandering. Which of the following alternatives to using a restraint would be chosen to use with this client?
A) Place a rocking chair in her room. B) Wedge pillows against the side rails on the bed. C) Assign this client to the farthest room from the nurses' station. D) Pull up all the side rails on the bed. |
A
Placing a rocking chair in the client's room will help her to expend some of her energy so that she will be less inclined to walk and wander. Pulling up all the side rails is a restraint, so that action would not be an alternative. Assigning the client to the farthest room from the nurses' station would be an unsafe move toward the client; closer would be safer than farther. Keeping pillows wedged against the side rails will not keep the client from wandering. She is not in the bed. |
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The RN has just stuck herself with a syringe while dropping it into a sharps container that was too full in a client's room. Which of the following steps should be taken next, for a puncture?
A) Complete an injury report. B) Encourage bleeding. C) Initiate first aid. D) Wash/clean the area with soap and water. |
B
Encouraging bleeding,initiating first aid, completing an injury report, and washing and cleaning the area with soap and water are all steps to be taken with a puncture wound. But encouraging bleeding is the first step. |
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Which of the following would be an example of medical asepsis?
A) Administering parenteral medications B) Changing a dressing C) Performing a urinary catheterization D) Using personal protective equipment |
D
Using personal protective equipment is a technique used in demonstrating medical asepsis. Administering parenteral medications, changing a dressing, and performing a urinary catheterization are all techniques that require surgical asepsis. |
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Which of the following nursing interventions would be appropriate in reducing the risk of infections?
A) Assess the vital signs only once daily. B) Raise the temperature in the client's room. C) Wash hands. D) Wear a mask for all client care. |
C
Washing hands is always the first and best way to stop the spread of microorganisms,which cause infections. Assessing vital signs is important butt should be taken more frequently that once daily. Wearing a mask for all clients is not practical and is not necessary unless a microorganism is airborne and the client is in isolation. Raising the temperature in the client's room would contribute to the growth of microorganisms. |
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Which of the following nursing interventions should be performed first when removing gloves?
A) Drop the gloves into the appropriate waste receptacle. B) Ease the fingers into the gloves. C) Grasp the outside of the non dominant glove. D) Hook the bare thumb inside the other glove. |
C
In order to remove gloves after use, one must grasp the outside of the non dominant glove. Hooking the care thumb inside the other glove, and dropping the gloves into the appropriate waste receptacle will come after the gloves are removed. Easing the fingers into the glove is an intervention used when applying gloves. |
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Which of the following nursing measures is appropriate in breaking a link in the chain of infection?
A) Cover one's mouth and nose when sneezing. B) Place contaminated linens in a paper bag. C) Use personal protective equipment (PPE) sparingly. D) Wear gloves at all times. |
A
Covering one's mouth and nose when sneezing prevents airborne droplets from escaping into the air for others to contract in the chain of infection. Placing linens in a paper bag would allow germs to come out through the bag, and the linen would act as a formite thus allowing the chain to continue. PPE,according to OSHA standards, has to be used whenever the situation dictates,not just to save money. Gloves have to be worn, but are to be changed between clients and hands washed. |
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The RN is conducting a staff in-service on Standard Precautions. Which of the following statements is correct and should be included in the presentation?
A) Cut the needle off a syringe after using it to give a client an injection. B) Dispose of blood-contaminated materials in a biohazard container. C) Gloves should not be worn for client care unless body fluids are seen. D) Wear a mask when in direct contact with all clients. |
B
Disposal of blood-contaminated materials in a biohazard container is a Standard Precaution. Needles should never be cut,bent,or altered in any way as this would place the health care provider at risk to be stuck. Gloves should be worn when providing client care whether body secretions are seen or not. Masks need not be worn when giving routine direct client care unless the client's condition so warrants. |
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Which of the following circumstances would render a client with active immunity?
A) Becoming ill with tetanus after receiving a tetanus toxoid B) Having chickenpox C) Receiving a rabies shot after being bitten by a rapid dog D) Receiving an injection of gamma globulin |
B
When the client has the disease, the body stimulates the process of acquired active immunity. Receiving injections for rabies,tetanus, and gamma globulin are examples of artificially acquired passive immunity. |
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Which of the following physiological mechanisms helps defend the body against microorganisms?
A) Heavy smoking B) Moisturizing the skin C) Breakdown of skin D) Voiding quantity sufficient |
D
Voiding quantity sufficient is a barrier that helps the body defend itself against microorganisms. The act of voiding flushes those organisms that might try to enter the body through the urinary meatus. Heavy smoking does not defend the body from microorganisms, it destroys the cilia in the nose and that helps to filter organisms. Moisturizing of the skin andbreakdown of the skin can both allow microorganisms to enter the body. |
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The unit has been notified that a client with tuberculosis is on the way up. Which of the following actions demonstrated by the staff shows measures of preventing the transmission of this disease?
A) Have the client wear a mask when coming from admission. B) Stock the supply cart at the beginning of each shift. C) Wash the hands only after leaving the room. D) Wear a mask when exiting the room. |
A
When a client has an airborne disease and must go elsewhere in the hospital, the client must wear a mask. Supplies to prevent transmission of disease should be stocked at the end of the shift so that adequate supplies will be available for the next health care provider. The mask should be removed just as the staff leaves the client's room ,not when coming out of the room. Hands should be washed before and after client care. |
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Which of the following techniques best exhibits surgical asepsis?
A) Disinfecting an item before adding it to a sterile field B) Allowing sterile gloved hands to fall below the waist C) Suctioning the oral cavity of an unconscious client D) Touching only the inside surface of the first glove while pulling it onto the hand |
D
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Multiple severely injured clients have arrived in the emergency department. On rapid assessment, the nurse notes that a leg wound dressing has a 4 cm × 6 cm blood spot that has soaked through the bandage. The client is otherwise stable. What action should the nurse take?
A) Add additional dressing to the wound without removing the original. B) Remove the dressing and place direct pressure on the wound. C) Remove the dressing and replace it with a new sterile dressing. D) Place a tourniquet above the wound. |
A
In this scenario, where there are multiple clients in need of care and since this client is stable, the correct nursing action is to add additional dressing to the wound without removing the original. A tourniquet should not be applied because of the risk of interrupting arterial flow to the tissues. Removing the dressing and applying direct pressure or replacing the dressing with a new sterile dressing would take too much time at this point. |
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The RN has been assigned to a client who is newly diagnosed with diabetes. What should the nurse include in the plan for foot care for this client?
A) Inspect feet thoroughly once a week. B) Dry toes thoroughly. C) Cut toenails around and file. D) Wash feet with water at a temperature of 90°F to 98.6°F. |
B
Toes should be dried thoroughly after being washed to impede fungal growth and prevent maceration. Toenails should be cut straight across, and nurses do not cut diabetic clients' toenails. Only a podiatrist should handle this task. The water to wash the feet should be 100°F to 110°F. Feet should be inspected each day, not once a week, for early detection of any problems. |
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The client has a documented stage III pressure ulcer on the right hip. What NANDA nursing diagnosis problem statement is most appropriate for use with this client?
A) Altered Tissue Perfusion B) Impaired Skin Integrity C) Risk for Injury D) Impaired Tissue Integrity |
D
Since a stage III pressure ulcer involves tissues, not just skin, this client has criteria for using the NANDA nursing diagnosis problem statement Impaired Tissue Integrity. Impaired Skin Integrity deals with the epidermal and dermal layers only and does not extend into the tissue. This client has already suffered injury, so this is not a Risk for Injury situation. While it is true that pressure ulcers result from Altered Tissue Perfusion, the diagnosis problem statement Impaired Tissue Integrity is more specific. |
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An 80-year-old client with gallbladder disease has had a cholecystectomy. Which of the following factors would influence this client's susceptibility to produce an infection?
A) Active bowel sounds B) Intact mucous membranes C) Dry skin D) Susceptibility of the client |
D
How susceptible the client is for an infection is one of the factors that influences microorganism growth. This client is 80 years old and has a surgical incision, so the first line of defense, the skin, is not intact. Active bowel sounds, dry skin, and intact mucous membranes are factors that help defend the body against infection. |
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The nurse assesses an open area over a client's greater trochanter that is approximately 10 cm in diameter. The tissue around the area is edematous and feels boggy. The edges of the wound cup in toward the center. Which additional finding would indicate to the nurse that this is a stage IV pressure ulcer?
A) The ulcer has thick dark eschar over the top. B) The joint capsule of the hip is visible. C) There is undermining of adjacent tissues. D) The crater extends into the subcutaneous tissue. |
B
The difference between a stage III and a stage IV pressure ulcer is the depth to which the ulcer extends. Stage III ulcers extend down to, but not through, the underlying fascia. Stage IV ulcers demonstrate damage to muscle, bone, tendons, or the joint capsule. Both stages can include undermining of adjacent tissues. If there is eschar present, the ulcer cannot be staged. Staging can occur only when the bottom of the ulcer can be seen and evaluated. |
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The nurse is writing the plan of care for a client who is confined to bed. Which intervention should be included to help reduce the effects of shearing forces on the client's skin?
A) Use a turn sheet lifted by two staff members to move the client in bed. B) Dust the linens with cornstarch each morning to allow for easier movement. C) Keep the head of the client's bed at 30 degrees. D) Coat the client's back and buttocks with baby powder after bathing. |
A
The nurse should plan to use a turn sheet lifted by two staff members to move the client up in bed. The head of the client's bed should be kept at less than 30 degrees elevation as much as possible. Baby powder and cornstarch should not be used as both agents cause abrasive grit damage to tissues. |
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Which of the following interventions promotes safe handling of a client's dentures?
A) Fill emesis basin half full of tepid water. B) Rinse dentures thoroughly with hot water. C) Replace the upper dentures first. D) Clean biting surfaces. |
A
Filling the emesis basin half full of tepid water acts as a cushion for the dentures if accidentally dropped. Cleansing biting surfaces prevents bacteria, odor, and stain formation. Replacing the upper dentures first promotes comfort. Dentures should be rinsed thoroughly with tepid water, not hot water, because extreme temperatures will harm dentures. |
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Which of the following expected outcomes is correct for a client with the nursing diagnosis Self-Care Deficit related to cognitive impairment?
A) The client will be able to name the staff that works on the day shift. B) The client, with supervision, will brush her teeth. C) The nurse will stress the importance of adequate fluid intake. D) The client will eliminate safety hazards in her environment. |
B
A client with cognitive impairment would be able to brush her teeth but only with supervision. She would not voluntarily brush her teeth without prompting from the staff. Cognitive impairment limits the client's ability to understand and comprehend; therefore, stressing adequate fluid intake, naming the staff, and eliminating safety hazards are not within her realm of understanding. |
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The newly hired nurse learns that the facility uses the Braden Scale for Predicting Pressure Sore Risk to assess all new admissions. Before using this scale the nurse:
A) Must be certified. B) Should receive specific training. C) Is required to ask the client's permission. D) Has to obtain special assessment equipment. |
B
The nurse should receive specific training in the use of the Braden scale in order for assessment to be accurate. There is no need for certification. Simple in-house training by an experienced, competent nurse is sufficient. There is no specific permission required from the client. There is no special assessment equipment required. |
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The nurse is expected to shave a client when he is unable. Which of the following
steps is a correct procedure for shaving a client? A) Pull the skin taut with the dominant hand. B) Rinse the razor after each stroke. C) Use long strokes. D) Assist the client to a prone position. |
B
Rinsing the razor after each stroke keeps the cutting edge clean. The skin should be pulled taut with the nondominant hand-not the dominant-because this provides uniform shaving. Assist the client to a sitting position-not a prone position-because this is a more natural position. Short strokes should be used-not long strokes-because this provides for a closer shave without irritation. |
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The UAP reports a small skin tear on the client's forearm that occurred during a routine turn. After assessing the wound the nurse should:
A) Request a consult with the wound care nurse. B) Tell the UAP to reevaluate the wound in 20 minutes. C) Obtain a transparent dressing for the UAP to place on the wound. D) Cleanse the wound and apply a dressing. |
D
The nurse should go to the room, assess the wound, cleanse the wound, and apply a dressing. The UAP is not educationally prepared to evaluate or dress the wound. At this point a consult with the wound care nurse is not required. |
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The nurse is collecting a specimen from an infected wound. From which portion of the wound should the specimen be collected?
A) A pus-coated area on the side of the wound B) Intact skin at the edge of the wound C) Clean areas of granulation tissue D) Exudate in the bottom of the wound |
C
Microorganisms that are most likely to be responsible for wound infections live in viable tissue such as granulation tissue. Exudate and pus contain a variety of components and are unlikely to give good indication of what is causing the infection. The skin at the edge of the wound contains skin organisms that may or may not be present in the wound itself. |
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Which of the following nursing interventions should be performed first when removing gloves?
A) Hook the bare thumb inside the other glove. B) Grasp the outside of the nondominant glove. C) Drop the gloves into the appropriate waste receptacle. D) Ease the fingers into the gloves. |
B
In order to remove gloves after use, one must grasp the outside of the nondominant glove. Hooking the bare thumb inside the other glove, and dropping the gloves into the appropriate waste receptacle will come after the gloves are removed. Easing the fingers into the glove is an intervention used when applying gloves. |
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The night nurse is assuming care of a cardiac client who wears antiembolic stockings. How should this nurse manage assessment of the skin on this client's legs?
A) Assess the skin when the client removes the stockings at bedtime. B) Remove the stockings for this assessment. C) Review the morning assessment, but don't repeat it unless a problem occurs. D) Defer the assessment since the stockings are in place. |
B
The stockings should be removed to do this assessment. The nurse is responsible for assessing the skin under the stockings and should not assume that the morning nurse's assessment is still accurate 12 hours later. The stockings are worn day and night, so the client will not remove them for sleep. |
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A client has had a hemorrhoidectomy and has been ordered a sitz bath BID. Which of the following interventions is appropriate in assisting the client with his bath?
A) Leave the client sitting on the basin for 45 minutes. B) Place the sitz bath on the commode seat, and fill the reservoir with warm water at 110°F to 115°F. C) Have the client use the clamp on the tubing to regulate the flow of water. D) Flatten the reservoir bag on a hard surface and press on it to expel air. |
C
Having the client use the clamp on the tubing to regulate the flow of water is a correct intervention. Flattening the reservoir is performed when an ice bag or hot water bottle is filled. The time for a sitz bath usually ranges from 15 to 20 minutes, not 45 minutes. The water in the reservoir should be about 105°F, not 110°F to 115°F, which would be too hot. |
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Which of the following physiological barriers helps defend the body against microorganisms?
A) Moisturizing the skin B) Voiding quantity sufficient C) Breakdown of skin D) Heavy smoking |
B
Voiding quantity sufficient is a barrier that helps the body defend itself against microorganisms. The act of voiding flushes those organisms that might try to enter the body through the urinary meatus. Heavy smoking does not defend the body from microorganisms; it destroys the cilia in the nose that helps to filter organisms. Moisturizing the skin and breakdown of the skin can both allow microorganisms to enter the body. |
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Hygienic care that nurses provide to clients includes _______________ care.
A) Nutritional B) Hair C) Clothes D) Family |
B
Hygiene care consists of skin, hair, hands, feet, eyes, nose, mouth, back, and perineum. The client's clothes, family, and nutrition do not come under hygiene care. |
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Which of the following clients would be most at risk for a nosocomial infection?
A) An 86-year-old female client on steroid therapy B) A client in the emergency department with abdominal pain C) A 19-year-old woman in her first trimester of pregnancy D) A 72-year-old male client with COPD |
A
The client most at risk for a nosocomial infection is the client who is 86 years old and on steroid therapy. The very old and very young are most susceptible to infections. The 86-year-old client is also on steroid therapy, which compromises the immune system. A client in the emergency department with abdominal pain has just arrived in the facility, and not enough time has elapsed for this client to be considered to have a nosocomial infection. If this client has an infection, it would be community acquired. The 19-year-old female who is pregnant is at a low risk. The 72-year-old male with COPD is at a higher risk for infection than the 19-year-old due to his age and chronic respiratory condition, but the 82-year-old is older and has a weakened immune system because of taking steroids. |
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The RN has just stuck herself with a syringe while dropping it into a sharps container that was too full in a client's room. Which of the following steps should be taken next, for a puncture?
A) Wash/clean the area with soap and water. B) Encourage bleeding. C) Complete an injury report. D) Initiate first aid. |
B
Encouraging bleeding, initiating first aid, completing an injury report, and washing and cleaning the area with soap and water are all steps to be taken with a puncture wound. But encouraging bleeding is the first step. |
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The continuous quality improvement team is monitoring the nursing care of clean-contaminated wounds. Which operative wound would be excluded from this study?
A) Uncomplicated abdominal hysterectomy B) Breast biopsy C) Gastric resection D) Lung resection |
B
Clean-contaminated wounds are surgical wounds in which the respiratory, alimentary, genital, or urinary tract has been entered. These wounds show no evidence of infection. Of the wounds listed, the only one not meeting the criteria is the breast biopsy. |
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Which of the following interventions demonstrates the appropriate technique for removing a mask?
A) Loop the ties over the ears. B) Bend the strip at the top of the mask. C) Touch the mask by the strings only. D) Tie the strings in a bow. |
C
Touching the mask by the strings for both putting on and taking off is the appropriate intervention because the mask is considered contaminated. Bending the strip at the top of the mask, looping the ties over the ears, and tying the strings in a bow under the chin are all interventions used when applying a mask. |
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The emergency department physician has closed a laceration with tissue adhesive. The nurse provides the client with instruction regarding which type of wound healing?
A) Delayed closure B) Primary intention C) Open approximation D) Secondary healing |
B
The nurse should instruct the client regarding primary intention wound healing. The edges of these wounds are approximated and held together with sutures, bandages, or tissue adhesive. Scarring is minimal with these wounds. Secondary healing involves wounds that cannot be approximated and that must "heal in." These wounds are at higher risk for infection, take longer to heal, and are more prone to scarring. |
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Which of the following circumstances would render a client with active immunity?
A) Having chickenpox B) Becoming ill with tetanus and receiving tetanus toxoid C) Receiving a rabies shot after being bitten by a rabid dog D) Receiving an injection of gamma globulin |
A
When the client has the disease, the body stimulates the process of acquired active immunity. Receiving injections for rabies, tetanus, and gamma globulin are examples of artificially acquired passive immunity. |
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Which of the following techniques would be an example of medical asepsis?
A) Using personal protective equipment B) Changing a dressing C) Performing a urinary catheterization D) Administering parenteral medications |
A
Using personal protective equipment is a technique used in demonstrating medical asepsis. Administering parenteral medications, changing a dressing, and performing a urinary catheterization are all techniques that require surgical asepsis. |
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Which of the following instructions is given to a client in regard to a
hearing aid? A) Do not buy extra batteries. B) Do not use hair spray when wearing a hearing aid. C) Use a hair dryer while wearing a hearing aid. D) Marking the aid is not necessary when living in a long-term facility. |
B
Hair spray can clog a hearing aid, and clients are encouraged not to use it when the aid is in use. Extra batteries are needed to keep on hand because a battery only lasts 1 1/2 to 2 weeks. A hair dryer should not be used around the aid as heat can damage the aid. Marking the aid is necessary for a client living in a long-term facility because of the potentially high number of hearing aids. |
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Which of the following steps will provide comfort for the client during occupied bed change of linens?
A) Raise the side rail. B) Slide the mattress to the head of the bed. C) Place a bath blanket over the client. D) Allow for a toe pleat. |
D
Allowing for a toe pleat provides for client comfort. Placing the bath blanket over the client prevents unnecessary exposure. Sliding the mattress to the head of the bed makes it easier to tuck in the linens. Raising the side rail maintains client safety. |
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Which of the following actions by the RN would render a sterile field unsterile?
A) Keeping objects on the field 1 inch from the edge B) Keeping the sterile field in eyesight C) Transferring a sterile object to a sterile field with a gloved hand D) Grasping the edge of the outermost flap and opening it away from oneself |
C
Transferring a sterile object onto a sterile field with a gloved hand would render the field unsterile only if the gloves are sterile. Grasping the edge of the outermost flap and opening it away from oneself, keeping objects on the field 1 inch from the edge, and keeping the sterile field in eyesight are all actions that will maintain sterility of a field. |
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Which of the following purposes would the RN explain to the client is the reason for her daily bath?
A) To assess skin integrity B) To moisturize the skin C) To develop a nurse-client relationship D) To stimulate circulation |
D
The three major reasons for a bath are to remove waste products like perspiration, stimulate circulation, and refresh the client. Giving a bath to a client will allow the nurse to assess the skin, develop a nurse-client relationship, and moisturize the skin, but these are not the most important purposes. |
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After completing a scheduled every-2-hour turn by turning the client to the left side, the nurse notices a reddened area over the coccyx. The area blanches when the nurse compresses it with thumb pressure. One hour later, the nurse reassesses the area and finds the redness has disappeared. How should the nurse document this area?
A) Reactive hyperemia B) Stage I pressure ulcer C) Stage II pressure ulcer D) Stage III pressure ulcer |
A
If the reddened area blanches with thumb pressure and disappears in one-half to three-quarters of the time pressure was on the area, the condition is reactive hyperemia and no damage to the skin and tissues has occurred. Stage I pressure ulcers are reddened areas that do not blanch with thumb pressure and that do not clear in the allotted amount of time. Stage II pressure ulcers show partial-thickness skin loss and have the appearance of abrasions, blisters, or shallow craters. Stage III pressure ulcers demonstrate full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. |
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Which of the following groups of symptoms is most commonly found in a client
who has systemic infection? A) Palpitations, irritability, and heat intolerance B) Edema, rubor, heat, and pain C) Fever, malaise, anorexia, nausea, and vomiting D) Tingling, numbness, and cramping of the extremities |
C
Fever, malaise, anorexia, nausea, and vomiting are symptoms of a systemic infection. Edema, rubor, heat, and pain are symptoms of a local infection. Palpitations, irritability, and heat intolerance are symptoms of a thyroid condition. Tingling, numbness, and cramping of the extremities would indicate symptoms of hypocalcemia. |
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The RN is conducting a staff in-service on Standard Precautions. Which of the following statements is correct and should be included in the presentation?
A) Gloves should not be worn for client care unless body fluids are seen. B) Dispose of blood-contaminated materials in a biohazard container. C) Wear a mask when in direct contact with all clients. D) Cut the needle off a syringe after using it to give a client an injection. |
B
Disposal of blood-contaminated materials in a biohazard container is a Standard Precaution. Needles should never be cut, bent, or altered in any way as this would place the health care provider at risk to be stuck. Gloves should be worn when providing client care whether body secretions are seen or not. Masks need not be worn when giving routine direct client care unless the client's condition so warrants. |
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The surgical report of a newly transferred client indicates that there was a great deal of intestinal spillage into the abdominal cavity during the client's bowel resection. For which category of wound should the receiving nurse plan care?
A) Clean-contaminated B) Infected C) Contaminated D) Dirty |
C
A surgical wound in which there is a large amount of spillage from the gastrointestinal tract is considered a contaminated wound. Clean-contaminated wounds are surgical wounds in which the respiratory, alimentary, genital, or urinary tract has been entered, but minimal to no spillage has occurred. A dirty or infected wound is one that contains dead tissue or that has evidence of a clinical infection, such as purulent drainage. |
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The nurse is selecting dressings for a clean abdominal incision that will be allowed to heal by secondary intention. What principles should the nurse use in choosing this dressing?
A) Materials used in dressing this wound should keep the wound bed moist. B) Absorbent material to wick exudates away and support drying should be used. C) Dressings should be simple as they will be changed at least every 4 hours. D) The dressing should allow good air circulation through the wound. |
A
Wounds that are expected to heal by secondary intention heal by "granulating in." In order to support the growth of granulation tissue, the wound bed should be kept moist and oxygen should be kept out of the wound. Air is drying to tissues and contains oxygen, so air circulation through the dressing is not desirable. The dressings will not be changed that often. Since the goal is to keep the wound bed moist, dressings should not wick exudates away. |
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Which of the following steps is correct in removing a client's soft contact lens?
A) Gently pinch the lens and lift it out. B) Have the client look up. C) Use the pad of the ring finger. D) Pull the lower eyelid upward. |
A
Gently pinching the lens and lifting it out is one of the correct steps for removing a client's soft contact lens. The nurse should have the client look straight ahead, not up. The upper eyelid is pulled down gently. The nurse would use the pad of the index finger, not the ring finger. |
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Which nursing intervention should take priority when giving a bath to a surgical client on his first post-op day?
A) Remove the soiled dressing during the bath. B) Apply lotion to the extremities. C) Raise side rails when gathering supplies. D) Change the water when it becomes cold. |
C
Raising the side rails would take priority when planning care. This is a safety issue, and safety is second on Maslow's hierarchy of needs. The client is only 1 day postop and may still be sedated, posing a risk for a potential fall. Changing the water needs to be done before it becomes cold, but raising the side rail first in order to get the water takes priority. Applying lotion to the skin and a dressing change would be performed before or after, not during, the bath and only with a doctor's order. |
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Which of the following assessment findings would be normal with the client's hair when giving her a shampoo?
A) Dry, dark, thin B) Smooth texture and not oily or dry C) Tender, warm scalp D) Smooth, taut, shiny |
B
The hair should be smooth in texture and neither oily nor dry. Skin is assessed as being smooth, taut, or shiny, not hair. The hair should not be dry or thin. This could be a sign of alopecia. Darkness would depend on hair color through the gene pool. A tender, warm scalp could indicate a problem, so this would not be normal. |
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Which of the following activities would be included in taking care of a client's artificial eye?
A) Firmly pat dry. B) Drape the client. C) Clean regularly. D) Apply lubricant. |
C
The eye and orbit should be cleaned regularly to remove any exudates that may be present. A lubricant is not necessary as it could cause damage to the prosthesis. Draping the client is not necessary, but providing privacy by pulling the curtain or shutting the door to the room may make the client more comfortable. The area should be gently dried once cleaned, but firmly patting dry may cause damage. |
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Which of the following techniques best exhibits surgical asepsis?
A) Disinfecting an item before adding it to a sterile field B) Touching only the inside surface of the first glove while pulling it onto the hand C) Allowing sterile gloved hands to fall below the waist D) Suctioning the oral cavity of an unconscious client |
B
Touching only the inside surface of the first glove while pulling it onto the hand is the correct technique when applying sterile gloves. This prevents contamination of the outside of the glove, which must remain sterile. Disinfecting an item is an example of medical asepsis, not sterile. If sterile gloved hands fall below the waist, they are considered to be unsterile. Suctioning the oral cavity of a client is considered contaminating. |
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Which of the following nursing interventions demonstrates the correct technique to remove a grossly soiled gown when leaving isolation?
A) Grasp the sleeve of the dominant arm, and remove it with a gloved hand. B) Release the neck ties of the gown and allow the gown to fall forward. C) Untie the strings at the waist first. D) Untie the strings at the neck first. |
C
To leave an isolation room where a gown has been worn, one must untie the gown at the waist first, not at the neck. Gloves are removed next. They are not left on while taking the gown off as stated in option A. After the neck ties are untied, the gown is allowed to fall forward. |
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A client has had Braden scores of 18 and 19 and Norton scores of 15 and 17 over the last 2 months. Is trending of these scores significant?
A) No, trending can only be accurate if the same scale is used. B) No, the scores indicate opposite risks for pressure ulcer development. C) Yes, there is a definite trend of low risk for pressure ulcer development. D) Somewhat, but trending would be more accurate if the same scale was used. |
D
All of these scores indicate risk for development of a pressure ulcer, so some trending is possible, but it would be more accurate if the same scale was always used. |
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The client is routinely taking steroid medications to control lung disease. In the discharge teaching plan the nurse includes information on practicing good infection control because steroids cause which of the following?
A) Suppression of the inflammatory process necessary for healing B) Blood vessel constriction which impairs waste product removal C) Decrease in the amount of nutrients such as glucose in the blood D) Decreased oxygen supply to tissues |
A
Steroids suppress the inflammatory process, which is a normal part of the healing process. While lung disease may affect oxygenation, the steroid drug regimen would not be implicated in decreased oxygen delivery to tissues. Steroids generally increase blood glucose. Blood vessels are not constricted by steroids. |
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The unit has been notified that a client with tuberculosis is on the way up. Which of the following actions demonstrated by the staff shows measures of preventing the transmission of this disease?
A) Wear a mask when exiting the room. B) Stock the supply cart at the beginning of each shift. C) Wash the hands only after leaving the room. D) Have the client wear a mask when coming from admission. |
D
When a client has an airborne disease and must go elsewhere in the hospital, the client must wear a mask. Supplies to prevent transmission of disease should be stocked at the end of the shift so that adequate supplies will be available for the next health care provider. The mask should be removed just as the staff leaves the client's room, not when coming out of the room. Hands should be washed before and after client care. |
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Which of the following nursing interventions should be applied to a client with a nursing diagnosis of Risk for Skin Integrity Impairment related to immobility?
A) Restrict fluid intake. B) Keep linens dry and wrinkle-free. C) Turn client every 3 hours. D) Encourage client to eat at least 40% of meals. |
B
Keeping linens dry and wrinkle-free will prevent pressure areas. For nutritional support to promote healthy tissue, clients should consume more than 40% of their meals. Fluids should not be restricted unless some other physical condition dictates. The skin should be kept hydrated. To relieve pressure, the client should be turned every 2 hours, not every 3. |
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Which of the following techniques is used to remove a client's artificial eye?
A) Compress the upper eyelid in, and pop out the eye from the supraorbital bone. B) Grasp the upper eyelid, and turn it inside out. C) Use the thumb and index finger to grasp hold of the eye. D) Retract the lower eyelid down over the infraorbital bone while exerting slight pressure below the eyelid. |
D
Retracting the lower eyelid down over the infraorbital bone while exerting slight pressure below the eyelid is the correct technique for removing an artificial eye. Compressing the upper eyelid will not allow the eye to come out. The nurse's fingers cannot get a grasp of the eye with the thumb and the index finger; the suction needs to be released first. Turning the upper eyelid inside out will not release the suction. |
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Which of the following situations could pose a threat to a client's personal hygiene?
A) The room temperature is set at 72°F. B) A German client refuses to bathe everyday. C) A client performs meticulous foot care. D) A client has a newly formed ileostomy. |
D
Some of the factors that influence one's personal hygiene are social practices, body image, knowledge of physical condition, and cultural variables. A client who has had an ileostomy has had a body image change which can greatly influence whether he will care for it or rely on others. This can pose a threat if the client chooses not to care for it. Performing meticulous foot care, bathing every other day, and room temperature of 72°F do not pose a threat to one's hygiene. |
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Which of the following items most likely would be included in the room of a client who is on contact isolation?
A) Sign on the door B) Paper towels, sink, and blood pressure cuff C) Cards and records D) Cabinet stocked with gloves and gowns |
B
Paper towels and a sink for hand washing should be in the client's room so they can be used before the staff leaves the room. A blood pressure cuff is needed to stay in the client's room to prevent cross contamination. A cabinet stocked with gloves and gowns would be on the outside of the room. Cards and records should never be taken into an isolation room. The sign explaining the kind of isolation should be on the outside of the door to alert the staff of what is needed to enter. |
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Emergency medical services contacts the emergency department with the report that they are transporting a client who was the victim of a motor vehicle crash. The paramedics report that the client is stable, but has multiple contusions. How should the nurse prepare for this client?
A) Notify the surgical staff that a surgical client will soon be arriving. B) Organize suture material to close the wounds. C) Request gauze to pack the wounds. D) Obtain ice packs to apply to the wounds. |
D
Contusions are closed wounds in which the skin is ecchymotic or bruised due to damage of blood vessels. These wounds are treated with ice pack application for the first 24 hours. Since these wounds are closed, there is no need for packing, suturing, or surgery. |
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Which of the following instructions is the most important to give a client who is about to be discharged and has a surgical wound?
A) Adjust your diet so it contains more fruits and vegetables. B) Apply lubricating lotion to the edges of the wound. C) Thoroughly irrigate the wound with hydrogen peroxide. D) Notify your physician if you notice edema, heat, or tenderness at the wound site. |
D
A client being discharged with an open surgical wound has to be instructed on the detection of infection since the skin is the first line of defense. Signs such as edema, heat, and tenderness would indicate a local infection. Increasing fruits and vegetables would increase vitamin C, which helps with wound healing, but more protein would be the best choice. Applying lubricating lotion to the edges of a wound would impede the healing process. Irrigating with hydrogen peroxide would break down good granulating tissue, so this also would not increase healing. |
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On the fourth postoperative day, the client has a sudden coughing episode and tells the nurse that "something popped" in the abdominal incision. Upon inspection, the nurse finds that evisceration has occurred. What nursing action should be taken first?
A) Cover the area with a large saline-soaked dressing. B) Pack the wound with nonadherent gauze. C) Notify the client's surgeon. D) Position the client in bed with knees bent. |
A
Evisceration occurs when an abdominal wound opens and there is protrusion of the internal viscera through the incision. The nurse's first action should be to cover the area with a large saline-soaked dressing to keep the viscera moist. While notifying the surgeon and positioning the client are important, covering the wound is the priority. Nothing should be packed into this wound. |
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Which of the following interventions is appropriate for a client who has been bitten by a rabid raccoon?
A) An injection of immunoglobulin B) An immunization for rabies C) A tetanus toxoid injection D) Mother's breast milk with antibodies in it |
B
Receiving an immunization for rabies is an example of artificially acquired passive immunity. Receiving tetanus and immunoglobulin are also examples but not specifically for rabies. Mother's breast milk is another example of passive immunity, but not for rabies. |
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The nurse is preparing to administer eardrops to a 6-year-old. What nursing action is correct?
A) Insert the tip of the applicator into the ear canal. B) Press gently on the tragus of the ear a few times after administration. C) Put the eardrops in the refrigerator for 10 minutes prior to administration. D) Pull the earlobe down and back to straighten the ear canal. |
B
The nurse should press gently but firmly on the tragus of the ear after eardrops are administered in order to direct the drops into the ear canal. After age 3, the pinna of the ear should be pulled up and back to straighten the ear canal. The tip of the eardrop applicator should not be placed into the ear canal, but should be held just above the canal so that the drops can fall onto the side of the canal. Eardrops should be warmed prior to administration, not cooled. |
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Which of the following are the most frequent undesirable effects of thrombolytic treatment?
A) Allergic Reactions B) Nausea and vomiting C) Diaphoresis D) INternal and even external bleeding |
D
Clot destruction is governed by the fibrinolytic system.Thrombolytics are anticoagulants that break down or lyse preformed clots. |
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While administering an intramuscular injection, the nurse notes blood return in the syringe barrel after aspirating. What action should the nurse take?
A) Pull the needle out 1/4 inch and inject the medication. B) Inject the medication as planned. C) Notify the physician immediately. D) Discard the medication and start over. |
D
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The nurse is preparing to administer a medication that the agency designates as "high alert." What action should the nurse take?
A) Decline to administer the medication unless there is a physician present. B) Call the pharmacist to check the efficacy of the medication. C) Request that the nursing supervisor administer the medication. D) Ask another registered nurse to verify the medication. |
D
Most health care agencies maintain a list of high-alert medications, including controlled substances, which require the verification of two registered nurses. While the pharmacy is a valuable resource for nurses, the "high-alert" designation does not require pharmacy intervention. High-alert medications do not require the presence of a physician or nursing supervisor for administration. |
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In a formerly independent geriatric patient who is being discharged to the care of a family member, one of the most important interventions prior to discharge is:
A) Communicate with empathy and patience. B) Suggest that the patient may have a need for a skilled nursing facility. C) Develop and instruct a detailed medication plan for this family. D) Refer the patient to several health care providers for a multiprovider paln. |
C
Patient and family education regarding medication administration prior to discharge is a Standard of Nursing Practice. |
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Pharmacokinetic Changes in the geriatric patient include:
A) Frequent nausea and vomiting B) Slowed Gastric emptying because of a decline in muscle tone and motor activity. C) Inability to understand the different indications of the medications. D) Allergies to drugs. |
B
Movement through the GI tract is slower becuase of decreased smooth muscle tone an dthe absorptive surface is decreased because the aging process blunts and flattens villi. |
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The nurse identifies that the ordered dose for a medication is twice the amount generally administered. What action should the nurse take?
A) Administer only the standard dose of the medication. B) Administer the medication as it was ordered. C) Collaborate with the prescriber about the order. D) Check to see if previous shift nurses gave the medication. |
C
When the nurse has doubts about the correctness of a medication or medication dose for a specific client, collaboration with the prescriber is necessary. The nurse is legally and ethically responsible for all actions taken, including medication administration. The fact that previous nurses gave the medication as ordered does not make it the correct action. The nurse cannot change the amount of medication to give without collaborating with the prescriber. Administering the dose as ordered may harm the client. |
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The hospitalized client has an order for Tylenol 325 mg 2 tablets every 4 hours prn temperature over 101°F. The client complains of a headache. Can the nurse legally administer Tylenol to treat the headache?
A) No, not unless the client also has a temperature over 101°F. B) Yes, but the nurse should document the reason why the medication was administered as a temperature elevation. C) Yes, since Tylenol is used both for fever and headache. D) Yes, since the medication is available over the counter, an order is not required. |
A
In the hospital setting, the nurse can only administer medications that are prescribed for the client and can only administer those medications according to the specifics of the prescription. In this case, the medication was ordered for temperature elevation, not pain, so the nurse cannot legally administer the Tylenol to treat the client's headache. The fact that this is an over-the-counter medication and is used both for fever and headache is not pertinent to the nurse's decision. The nurse should never document false information in regard to medication administration. |
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During administration of an intradermal injection, the nurse notices that the outline of the needle bevel is visible under the client's skin. How should the nurse proceed?
A) Recognize that this is an expected finding in a properly administered intradermal injection. B) Withdraw the needle, prepare a new injection, and start again. C) Insert the needle further into the skin at a deeper angle. D) Turn the needle so that the bevel is down and inject the medication slowly, looking for development of a bleb. |
A
This is the expected outcome for this administration. Withdrawing is unnecessary - Deeper would not be intradermal - the bevel down would not be a correct postion. |
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Before administering any medication to a pediatric patient, a thorough health and medication history must be obtained that includes the following: (check all that apply)
A) Usual response to medications B) Level of growth and Development C) Use of prescriptions and OTC medications D) Allergies to foods and drugs E) All of the above |
E
The prescriber's orders should be triple checked becuase there is no room for error. The medication dosage should be calculated and rechecked for safety purposes. |
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The nurse is preparing to administer a medication that the agency designates as "high alert." What action should the nurse take?
A) Decline to administer the medication unless there is a physician present. B) Call the pharmacist to check the efficacy of the medication. C) Request that the nursing supervisor administer the medication. D) Ask another registered nurse to verify the medication. |
D
Most health care agencies maintain a list of high-alert medications, including controlled substances, which require the verification of two registered nurses. While the pharmacy is a valuable resource for nurses, the "high-alert" designation does not require pharmacy intervention. High-alert medications do not require the presence of a physician or nursing supervisor for administration. |
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The nurse has discontinued suction to a nasogastric tube to administer medication. For how long should the nurse plan to leave this suction discontinued?
A) 10 to 20 minutes B) 20 to 30 minutes C) 30 to 40 minutes D) 10 to 15 minutes E) Connect suction immediately after administration |
B
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The nurse is preparing to discharge several clients from the hospital. All of the clients require medications and special diets at home. The nurse will assess financial status of which clients in particular, who may be most in need of financial assistance to obtain medications and proper food?
A) A 60-year old Caucasian male B) A 90-year old Caucasian female C) A 75-year old African-American male D) An 87 year old African-American female |
D
Objective: Describe the demographic socioeconomic, ethnicity and health characteristics of elders in the US.Rationale: Financial needs of elders vary widely, but minority elders often have greater financial problems than elderly whites, and all elderly women tend to have lower incomes than men, with oldest women the poorest. |
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In evaluating a research question regarding the safety of pharmacological interventions used to stop preterm labor, the nurse looks specifically at the various medications used and what effect, if any, they had on the baby. The nurse is critiquing the research based on which dimension?
A) Interpretive B) Methodologic C) Presentation and stylistic D) Substantive and theoretical |
D
For substantive and theoretical dimensions, the nurse needs to evaluate the significance of the research problem (preterm labor is a critical concern in obstetric nursing) and the congruence between the research question and the methods used to address it (in this case, using accepted means to treat preterm labor). Methodologic dimensions pertain to the appropriateness of the research design, of which we have no information for this situation. To critique interpretive dimensions, the nurse needs to ascertain the accuracy of the discussion, conclusions, and implications of the study results (no information is given regarding the results in this situation). The manner in which the research plan and results are communicated refers to the presentation and stylistic dimensions. Again, we have no examples of this dimension for this scenario to critique. |
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Hospital regulations now require that the nurse write out the name of the drug morphine sulfate instead of using the abbreviation MS. What is the best rationale for this requirement?
A) The hospital has placed MS on its list of do not use abbreviations. B) Using the abbreviation MS puts the client at risk of medication error. C) JCAHO requires that the abbreviation MS not be used. D) Computerized charting systems will not accept the abbreviation MS. |
B
The best answer is that using the abbreviation MS puts the client at risk of medication error. Although the hospital has probably placed MS on its list of do not use abbreviations, JCAHO does require that the abbreviation not be used, and some computerized charting systems are set up not to accept the abbreviation, those considerations are secondary to the safety of the client. |
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The nurse is planning to administer a bitter-tasting oral medication to a 4-year-old. What strategy should this nurse plan?
A) Give the medication in orange juice or milk to mask the taste. B) Ask the parents how they give medications at home. C) Tell the child that the medication tastes good. D) Get another nurse to assist by holding the client down. |
B
Parents are a very good source of ideas for caring for their child, and their input should be sought when performing tasks such as medication administration. Medication should not be placed in essential foods such as orange juice or milk as the child may develop an aversion to the food related to the taste of the medication. Being untruthful about any interventions may cause the client to lose trust in the nurse. Having a second nurse hold the client down to administer the medication is an unnecessary use of force and will frighten the child. |
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A hospitalized elderly client is recovering from an acute illness. As the client nears the end of his hospitalization, he questions the nurse about medications and care after discharge. The nurse should:
A) Invite the client's family to come to the hospital so the nurse can explain the client's care to them. B) Tell the client not to worry about going home. C) Tell the physician the client needs to go to a nursing home. D) Assess the client's independence and ability to function in his own home before discharge. |
D
Older adults often perceive that being in the hospital could change their ability to be autonomous and independent. As a result, the nurse needs to assess the older adult's stage or perception of need for control and autonomy during his hospitalization and his fears and hopes about being discharged from the hospital setting. Telling the physician the client needs long-term care is inappropriate at this point. So is inviting the family to come so the nurse can explain the client's care to them. The client is a capable adult and should be included in all decision-making situations. Telling the client not to worry is not therapeutic and does not address his concerns. |
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Before administering medications via a gastrostomy tube on an adult, the tube must be flushed with:
A) 15-30 ml of water after administration B) 30-60 ml of water, between and after each medication C) 15-30 ml of water, between and after each medication D) 30-60 ml of water after administration |
C
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The nurse has just injected insulin subcutaneously into the client's abdomen. What action should the nurse take at this point?
A) Leave the needle embedded in the client's skin for 5 seconds after administration. B) Cover the injection site with a pressure dressing for at least 15 minutes or until the bleb disappears. C) Remove the needle rapidly by pulling it quickly from the skin. D) Massage the site to encourage absorption. |
A
The American Diabetes Association recommends leaving the needle embedded in the client's skin for 5 seconds after injection of medication, particularly insulin. This allows for complete delivery of the dose. Massage is contraindicated for most medications because it alters the delivery rate from the tissues. The needle should be removed slowly and smoothly to minimize pain for the client. Bleeding rarely occurs after subcutaneous injection, but short application of manual pressure (1-3 minutes) should cause bleeding to stop. There is no need for a pressure dressing for 15 minutes. Subcutaneous injections do not result in bleb formation. |
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A nurse is caring for a client who has unstable cardiac dysrhythmias. The client has orders for medications, one of which is by oral route, the other by IV delivery. The nurse realizes that the IV route would be fastest, but is also concerned about the side effects that this drug may produce and the fact that the client has never taken the drug, so any adverse effect is unknown. The nurse is implementing which step of the decision-making process?
A) Seek alternatives B) Project C) Implement D) Identify the purpose |
A
In this step, the decision maker (nurse) identifies possible ways to meet the criteria. Alternatives considered are which route to give a certain medication: IV versus oral. The nurse is utilizing his experience, taking what he knows about cardiac problems and pharmacology, and will make a selection based on that information. Identifying the purpose, in this case, would be determining that the client needs intervention to control the dysrhythmia. Projecting is when the nurse applies creative thinking and skepticism to determine what might go wrong as a result of a decision and develops plans to prevent, minimize, or overcome any problems. Implementation is taking the plan into action. |
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The nurse is preparing to administer eardrops to a 6-year-old. What nursing action is correct?
A) Insert the tip of the applicator into the ear canal. B) Press gently on the tragus of the ear a few times after administration. C) Put the eardrops in the refrigerator for 10 minutes prior to administration. D) Pull the earlobe down and back to straighten the ear canal. |
B
The nurse should press gently but firmly on the tragus of the ear after eardrops are administered in order to direct the drops into the ear canal. After age 3, the pinna of the ear should be pulled up and back to straighten the ear canal. The tip of the eardrop applicator should not be placed into the ear canal, but should be held just above the canal so that the drops can fall onto the side of the canal. Eardrops should be warmed prior to administration, not cooled. |
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The nurse is providing discharge teaching for a client who is being dismissed with prescriptions for a bronchodilator inhaler and a corticosteroid inhaler. What information should the nurse provide regarding the dosage schedule for these two medications?
A) Always use the corticosteroid inhaler first. B) It makes no difference which inhaler is used first. C) Use the inhalers on alternate days, not on the same day. D) Use the bronchodilator first. |
D
These two types of inhalers are frequently prescribed to be used together. The bronchodilator should be used first in order to open the airways so the corticosteroid medication can move deeply into the lungs. |
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The nurse administered analgesic medications to an assigned client via central line. This information should be documented in which section if using PIE charting?
A) Plan B) Evaluation C) Progress notes D) Intervention |
D
The interventions employed to manage the problem are labeled "I" and numbered according to the problem. The problem statement is labeled "P" and referred to by number. The "E" is evaluation of the effectiveness of the intervention and is also labeled and numbered according to the problem. Progress notes are not part of the identified labels of PIE charting. |
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A nurse has provided routine morning cares to a client, including all the medications and scheduled treatments. The most appropriate action after this is completed is for the nurse to:
A) Get supplies organized for the next client's medications and treatments. B) Document all cares in the progress notes. C) Move on to the next assignment to increase the nurse's efficiency. D) Report this to the charge nurse. |
B
After carrying out the nursing activities, the nurse completes the implementing phase by recording the interventions and client responses in the progress notes. Administering medications should be recorded when completed to prevent errors. At times, documentation may be done at the end of the shift, but in some instances, as in medication administration, it is important to record immediately after implementation. This information must be accurate and up to date for other nurses and health care professionals. Reporting to the charge nurse would be done at the end of the shift, unless the client's condition is not stable. |
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The nurse is preparing a small amount of medication for oral administration. Which nursing action is essential?
A) Draw up the medication in a syringe with a large-gauge needle. B) Dilute the medication with water before measuring. C) Label the syringe with the medication name, amount, and route. D) Measure the medication at the top of the meniscus. |
C
When measuring medication in a syringe, a label must be attached indicating the name of the medication, the amount, and the route. This labeling is essential to prevent the medication from being given via the wrong route. If a regular syringe is used to draw up the medication, the needle should be discarded. A syringe with a needle might also indicate that the medication is to be given parenterally and cause a medication route error. If medications are measured in a cup, the correct measurement is at the bottom of the meniscus. Medication might be diluted after measuring, but dilution before measurement will make it impossible to measure accurately. |
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During the process of administering medications, the nurse checks the name band for the client's name. What should be this nurse's next action?
A) Double check the client's identification using a second method. B) Administer the medication as ordered. C) Educate the client regarding the medication to be given. D) Initial the MAR that the medication will be given. |
A
The Joint Commission's National Client Safety Goals require a two-step check of client identification prior to the administration of medications. This nurse should employ a second method to verify the client's identification. After that verification, the nurse should educate the client regarding the medication, administer the medication as ordered, and only then should the nurse initial that the medication was given. |
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The nurse is caring for a client on a PCA pump with morphine. Which of the following medications should the nurse have readily available?
A) Diphenhydramine hydrochloride (Benadryl) B) Acetaminophen (Tylenol) C) Normal saline D) Naloxone hydrochloride (Narcan) |
D
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A client is being discharged from the hospital after a myocardial infarction and has several new medications that have been added to her therapy. She also has been prescribed to follow a low-fat diet. The client states: "I'm never going to understand what to do, when to do it, and why I should be doing all these things." The nurse formulates which of the following diagnoses for this client and her situation?
A) Risk for Myocardial Infarction related to deficient knowledge B) Deficient Knowledge (diet and medication regimen) related to inexperience C) Health-Seeking Behavior related to desire to prevent heart problems D) Noncompliance related to situational factors |
B
The NANDA label Deficient Knowledge is used when the client is seeking health information or when the nurse has identified a learning need, as in this case. The area of deficiency (diet and medication regimen) should always be included in the diagnosis. Health-Seeking Behavior is a diagnostic label used when the client is seeking health information, which is not the case here. Noncompliance is used when the client or caregiver fails to follow a plan, which is too early to tell in this case. Risk for Myocardial Infarction is not a NANDA label. If a risk exists, the label could be Risk for Noncompliance related to deficient knowledge. |
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The nurse is preparing to administer a medication to a 6-year-old. What is the nurse's priority action?
A) Administer no more than one-half of the safe adult dosage. B) Give the dosage supplied by the pharmacy. C) Administer the exact dosage as ordered. D) Verify that the dosage is within the safe range for this child. |
D
The priority action is to verify that the dosage is within the safe range for this child. This verification can be done by figuring the dose per kilogram of body weight or by use of a nomogram. This dose should be compared to the standard dose listed in a reputable drug reference book. This dose may be more or less than one-half the adult dosage. While prescribers and pharmacists are also responsible to figure the correct dose, the nurse who administers the dose is the last possible person to prevent a medication error. The nurse has the final responsibility to ensure that the dose ordered and dose supplied are correct for the client. |
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The client has been prescribed both a bronchodilator and a steroid medication that is delivered by inhaler. What information is essential to teach this client in regard to these medications?
A) The bronchodilator should be used only when absolutely necessary and only after the steroid inhaler. B) Both medications have the possible side effect of increased heart rate. C) The steroid inhaler should be used when immediate effects are necessary. D) The medications cannot be used on the same day. |
B
Both of these medications have the possible side effect of increased heart rate. The medications can be used on the same day. It is imperative for the client to understand that the steroid inhaler is not a "rescue" inhaler and should not be used for immediate relief. While the client should be taught to use both inhalers as infrequently as possible, the client should be taught to use the inhaler when necessary. When the inhalers are used together, the bronchodilator is used first, followed by the steroid. |
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Why is the Z-track method used for administering certain intramuscular medications?
A) To keep tissue irritation at a minimum. B) Reduction of pain at the site of the injection. C) Facilitating the action of the drug. D) The rate of absorption is controlled. |
A
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The nurse is adding medication to an existing intravenous setup. Which nursing action is indicated?
A) Do not remove the IV bag from the standard. B) Briskly shake the IV bag after injecting the medication. C) Ensure that the IV bag is full prior to adding medication. D) Close the infusion clamp. |
D
The nurse must close the infusion clamp prior to adding medication to an existing IV bag. Closing the clamp prevents the medication from inadvertently going directly down the tubing and into the client. Medication is frequently added to IV bags that are less than completely full. The nurse must make a determination if the bag contains enough fluid to dilute the medication to the desired strength. The bag can be taken from the IV standard for mixing. The bag should receive a gentle rotation, not brisk shaking, to mix the medication and the fluid. |
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Which is the primary reason why people stop taking their prescribed medications? They:
A) Are experiencing uncomfortable side effects B) Have cognitive impairment related to their chronic illness C) Are generally noncompliant with most medical treatments D) Received inadequate teaching about the prescribed drug |
A
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The client is taking meperidine (Demerol) and experiencing pruritus. Which of the following medications would the nurse expect the physician to order?
A) Diphenhydramine hydrochloride (Benadryl) B) Acetaminophen (Tylenol) C) Naloxone hydrochloride (Narcan) D) Normal saline |
A
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The client is taking meperidine (Demerol) and experiencing pruritus. Which of the following medications would the nurse expect the physician to order?
A) Acetaminophen (Tylenol) B) Naloxone hydrochloride (Narcan) C) Diphenhydramine hydrochloride (Benadryl) D) Normal saline |
C
When clients experience pruritus, an antihistamine, such as Benadryl, is ordered. |
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The nurse is caring for a team of four clients who are seriously ill. One of the clients has just received a new cardiac medication. How should the nurse instruct the unlicensed assistive personnel (UAP) who is also caring for this client?
A) Have the UAP assess for any unexpected effects from the medication. B) Have the UAP look the medication up in a drug reference book to read about drug actions and possible side effects. C) Tell the UAP to teach the client's family what to expect from the medication. D) Give the UAP specific instructions regarding what drug actions or side effects to report to the nurse. |
D
The nurse should give the UAP specific instructions about what drug actions or side effects should be reported to the nurse. The UAP does not have the skills or legal responsibility to assess the client, but can collect data to report to the nurse. It is also the nurse's responsibility to teach the client or family about the medications. The nurse should not expect that the UAP can determine from the drug reference book what drug actions and possible side effects are pertinent to this client. |
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The client is routinely taking steroid medications to control lung disease. In the discharge teaching plan the nurse includes information on practicing good infection control because steroids cause which of the following?
A) Suppression of the inflammatory process necessary for healing B) Blood vessel constriction which impairs waste product removal C) Decrease in the amount of nutrients such as glucose in the blood D) Decreased oxygen supply to tissues |
A
Steroids suppress the inflammatory process, which is a normal part of the healing process. While lung disease may affect oxygenation, the steroid drug regimen would not be implicated in decreased oxygen delivery to tissues. Steroids generally increase blood glucose. Blood vessels are not constricted by steroids. |
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The client who regularly uses a metered-dose inhaler four times a day tells the nurse that it is difficult to tell when the canister is empty. What instruction should the nurse give this client?
A) When you get a new canister, divide the number of puffs that is listed on the label by four. That will tell you how many days the canister will last. B) When you feel like you are no longer getting maximum effect from the medication, your canister is empty. C) Place the canister in a bowl of water. If the canister floats, it is not empty. D) You can tell that the canister is empty when you can no longer smell the medication when you activate the plunger. |
A
The best way to track the number of puffs left in a canister is to start with the new canister, dividing the number of puffs listed on the label by the number of puffs taken each day. The old method of floating the canister in water is not accurate as there may be propellant left in the canister after the medication is all dispensed. Being able to smell the medication is not an indication of the amount left in the canister. Waiting until there is lack of maximum effect from the medication may put the client at risk for respirator illness exacerbation. |
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The client is to receive an intramuscular injection of a medication that is supplied in a 2-mL cartridge and a second medication that is supplied in a vial. The total amount to be administered of these medications exceeds the volume of the cartridge by 0.5 mL. How should the nurse proceed?
A) Add as much of the vial medication to the cartridge as possible prior to injection, giving the balance in a separate injection. B) Draw both of the medications up into a syringe for administration. C) Administer the cartridge medication in one injection and the vial medication in a separate injection. D) Call the pharmacy for advice on administering these medications. |
B
When the total amount of medication to administer exceeds the volume of the cartridge, the medication is drawn up into a syringe and is administered. Giving two separate injections, no matter how the medication is divided, should be avoided if possible. There is no need for the nurse to consult the pharmacy for this standard technique. |
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The nurse identifies that the ordered dose for a medication is twice the amount generally administered. What action should the nurse take?
A) Administer only the standard dose of the medication. B) Administer the medication as it was ordered. C) Collaborate with the prescriber about the order. D) Check to see if previous shift nurses gave the medication. |
C
When the nurse has doubts about the correctness of a medication or medication dose for a specific client, collaboration with the prescriber is necessary. The nurse is legally and ethically responsible for all actions taken, including medication administration. The fact that previous nurses gave the medication as ordered does not make it the correct action. The nurse cannot change the amount of medication to give without collaborating with the prescriber. Administering the dose as ordered may harm the client. |
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A client asks the nurse about her medications and tells the nurse she has been investigating on the Internet. The nurse's best response to this is:
A) "I'm glad you're interested in your therapy." B) "Let's look at some of the sites you've been visiting." C) "Information on the Internet cannot be trusted. You should check with your pharmacist." D) "Your physician is the one you should be asking these kinds of questions." |
B
Thousands of health-related sites exist on the Internet, new ones occurring daily. There are no controls to ensure that information provided on these sites is accurate. Therefore, the nurse should help the client find reliable and accurate information. Clients are involved consumers. Wanting more information about their medications, disease processes, and treatment options is taking a proactive approach to their care. It is appropriate to ask questions and seek information at a variety of sources. However, nurses must assist clients in making sure the information they gather is credible and accurate. |
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The hospitalized client has an order for Tylenol 325 mg 2 tablets every 4 hours prn temperature over 101°F. The client complains of a headache. Can the nurse legally administer Tylenol to treat the headache?
A) No, not unless the client also has a temperature over 101°F. B) Yes, but the nurse should document the reason why the medication was administered as a temperature elevation. C) Yes, since Tylenol is used both for fever and headache. D) Yes, since the medication is available over the counter, an order is not required. |
A
In the hospital setting, the nurse can only administer medications that are prescribed for the client and can only administer those medications according to the specifics of the prescription. In this case, the medication was ordered for temperature elevation, not pain, so the nurse cannot legally administer the Tylenol to treat the client's headache. The fact that this is an over-the-counter medication and is used both for fever and headache is not pertinent to the nurse's decision. The nurse should never document false information in regard to medication administration. |
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A couple discusses their childbirth preparation options with the nurse. They want the father to be actively involved, and for the expectant mother to avoid medications during the birthing process. What is the nurse's best response?
A) "The hospital will follow your wishes." B) "The Leboyer method will provide what you want." C) "The Bradley method will meet your needs." D) "The Lamaze method will be easy to follow." |
C
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The nurse is to administer four oral medications to the client via a nasogastric tube. One of the medications is a tablet that has been crushed, one is a capsule that has been opened and the powder removed, and two are supplied in liquid form. How should the nurse administer these medications?
A) Flush the tube with the mixed liquids first, then administer the crushed tablet and capsule powder mixed in cold water. B) Mix the crushed tablet and capsule powder individually in warm water. Administer each medication separately, flushing the tube before and after each administration. C) Mix the crushed tablet and capsule powder in warm water and administer. Flush the tube and administer the mixed liquids. D) Flush the tube, mix the crushed tablet and the capsule powder into the two liquids for administration, and follow by flushing the tube. |
B
When giving medication via a nasogastric or gastric tube, the nurse should individually prepare and administer the medications, flushing the tube before and after each administration. Mixing medications together may result in a chemical reaction that occludes the tube. Failure to flush the tube adequately is the leading cause of tube occlusion. |
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Upon aspirating a saline lock prior to administering intravenous medication, the nurse notes that there is no blood return. What nursing action should be taken?
A) Discontinue this infiltrated lock and restart another site for medication administration. B) Pull the intravenous catheter out 1/8 inch and attempt aspiration. C) Reinsert the needle into the lock and aspirate using more pressure. D) Slowly infuse 1 mL of saline into the lock, assessing for infiltration. |
D
While the presence of blood upon aspiration confirms that the catheter is in a vein, the absence of blood does not rule out correct placement. If no blood returns, the nurse should slowly infuse 1 mL of saline into the lock while assessing the site for infiltration. If there is no infiltration present, the nurse should administer the medication. Simple lack of blood upon aspiration does not indicate infiltration, so there is no need to discontinue the site. Often the reason for absence of blood return is that the vessel has collapsed around the catheter from the pressure of aspiration. Increasing the pressure will not increase the likelihood of blood return. Pulling the intravenous catheter out 1/8 inch will not increase the likelihood of blood return and may make the site more unstable. |
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The nurse is planning to administer medications to a new client. What is the nurse's greatest priority in administering these medications?
A) Be certain the medications are given within 15 minutes of the time they are scheduled. B) Assess the client's knowledge of the action of the medications. C) Document the administration accurately so the reimbursement is correct. D) Before giving the medications, know what the intended effects are for this client. |
D
The nurse should be certain that all of these options occur. However, the greatest priority is to understand the intended effects of the medication for this client. The nurse should never do anything to or for a client without knowing the intended effect. |
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A review of a client’s current medications is necessary because of androgen drug interactions with which of the following?
A) Antihypertensives B) Antacids C) Insulin D) Nonsteroidal antiinflammatory drugs |
C
Correct Answer CAndrogens may lead to insulin resistance. |
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A patient with HIV infection will be starting on combination medications to manage her disease. As you discuss the medication schedule, you know all of the following predict improved adherence EXCEPT:
A) Her educational level B) A trusting relationship with her provider C) An expectation that the medication will be helpful D) Being able to take the medications twice daily instead of four times a day |
A
Correct, education has not been shown to be a factor in predicting adherence. There is good evidence that a trusting relationship with her provider, evidence supporting the effectiveness of the medication, and a less complex dosing regime are important predictors. |
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The client has a long history of hypertension and has developed heart failure. The nurse would anticipate giving medications to do which of the following?
A) Increase preload. B) Decrease cardiac output. C) Decrease contractility. D) Decrease afterload. |
D
The client likely has developed heart failure secondary to the hypertension, which is a increase in afterload. The nurse would anticipate giving medication to decrease afterload. There would be no reason to increase preload, decrease contractility, or decrease cardiac output. |
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While preparing to administer a transdermal estrogen patch, the nurse finds the previously applied patch in the client's bed linens. How can the nurse avoid this situation with the patch now being applied?
A) Run a finger around the adhesive edges of the new patch before placing it on the client's skin. B) Place a heating pad over the area where the patch is applied for 10 minutes after application. C) Shave the area where the patch is being applied. D) Press firmly over the patch with the palm of the hand for about 10 seconds after applying it to the skin. |
D
In order to affix the patch firmly to the client's skin, press firmly over the patch with the palm of the hand for about 10 seconds after application. Placement of a heating pad is contraindicated as the heat could increase circulation and the rate of absorption. Avoid touching the adhesive edges of the patch prior to placing it on the skin. If hair is a problem in keeping the patch on, choose a less hairy site for application or clip (do not shave) the hair. |
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The nurse is caring for a client on a PCA pump with morphine. Which of the following medications should the nurse have readily available?
A) Normal saline B) Diphenhydramine hydrochloride (Benadryl) C) Acetaminophen (Tylenol) D) Naloxone hydrochloride (Narcan) |
D
Narcan is an opioid antagonist and should be readily available when a client is receiving an opioid. |
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During administration of an intradermal injection, the nurse notices that the outline of the needle bevel is visible under the client's skin. How should the nurse proceed?
A) Insert the needle further into the skin at a deeper angle. B) Withdraw the needle, prepare a new injection, and start again. C) Turn the needle so that the bevel is down and inject the medication slowly, looking for development of a bleb. D) Recognize that this is an expected finding in a properly administered intradermal injection. |
D
Intradermal injections are given at a very shallow angle so that the medication is delivered into the area between the dermal layers. When properly given, the outline of the needle bevel will be visible prior to injection of the fluid. There is no need to withdraw the needle and start again. Inserting the needle further into the skin and at a deeper angle would result in delivery of the fluid into the subcutaneous tissues. The needle is inserted with the bevel up. |
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While administering an intramuscular injection, the nurse notes blood return in the syringe barrel after aspirating. What action should the nurse take?
A) Inject the medication as planned. B) Notify the physician immediately. C) Pull the needle out 1/4 inch and inject the medication. D) Discard the medication and start over. |
D
Blood return in the syringe barrel after aspiration indicates a strong probability that the needle tip is in a blood vessel. Injection of medication would then be intravenous, not intramuscular. The nurse should discard the medication and start over with new medication and a new syringe. Simply pulling out the needle 1/4 inch does not guarantee that the needle point is not in a vessel, and the presence of blood in the syringe prevents checking the new site. A second consideration is that injection of blood into the muscle is painful. There is no need to notify the physician of this event. |
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The pregnant client has asked the nurse what kinds of medications cause birth defects. Which statement would best answer this question?
A) "Too much vitamin C is one of the most common issues, but is avoidable." B) "Almost all medications will cause birth defects in the first trimester." C) "Birth defects are very rare. Don't worry; your doctor will watch for problems." D) "To be safe, don't take any medication without talking to your doctor." |
D
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The nurse who is to administer 2.5 mL of intramuscular pain medication to an adult client notes that the previous injection was administered in the right ventrogluteal site. In which site should the nurse plan to administer this injection?
A) The deltoid B) The left ventrogluteal C) The rectus femoris D) The same site |
B
Of the options given, the best choice is the left ventrogluteal. This is a site that will accept 2.5 mL of medication, and using the opposite site from the last injection will allow the first site time for recovery. The deltoid site will not accept 2.5 mL of medication. The rectus femoris site is generally used only for self-injection of medication and is a painful site for medication administration. |
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The nurse should recognize that an older adult needs instruction in self-administration of medications if she notices which of the following sensory deficits?
A) hearing deficit B) Deficit in taste C) Touch deficit D) deficit in vision |
D
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While preparing to administer an eye ointment, the nurse inadvertently squeezes the tube, discarding the first bead of medication. What action should the nurse take at this point?
A) Administer the eye ointment as ordered, as the first bead of ointment should be discarded anyway. B) Have a second licensed nurse witness the waste and sign the chart. C) Notify the pharmacy and request a new, unopened tube of ointment. D) Continue to squeeze the tube until a clear line of ointment has been discarded from the tip. |
A
The nurse should administer the eye ointment as ordered as the first bead of ointment is considered contaminated and should always be discarded. There is no need to notify the pharmacy for a new tube of ointment or to have the wastage witnessed by another nurse. It is necessary to discard only the first bead of ointment, not an entire line. |
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The laboring client participated in childbirth preparation classes that strongly discouraged the use of medications and intervention during labor. The client has been pushing for two hours, and is exhausted. The provider requests that a vacuum extractor be used to facilitate the birth. The client first states that she wants the birth to be normal, then allows the vacuum extraction. Following this, what should the nurse assess the client for after the birth?
A) Uncertainty surrounding the baby's name B) Elation, euphoria, and talkativeness C) Questions about whether or not to circumcise D) A sense of failure and self-disappointment |
D
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At which point of preparing medication from an ampule does the nurse anticipate using a filter needle?
A) When administering the medication to the client. B) Both for drawing up the medication and for administering the medication. C) When drawing the medication from the ampule. D) Filter needles are not used for this preparation. |
C
The nurse uses a filter needle to draw medication up from an ampule to remove any possible shards of glass from the liquid. The filter needle is then changed to a regular needle prior to administering the liquid to the client. If the filter needle was used to inject the client, the trapped shards of glass would be injected into the muscle. |
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The diabetic client asks the clinic nurse about the advisability of reusing insulin syringes. Assessment reveals that the client has poor personal hygiene and difficulty with fine motor skills. The nurse also knows the client has financial difficulties. What instruction should the nurse give this client?
A) "The American Diabetes Association advises that syringes are single use only." B) "Only people who practice good personal hygiene can reuse syringes." C) "In order to save money, I advise you to reuse syringes up to three times or until the needle feels dull." D) "All clients are different, but I advise you to use a new syringe each injection." |
D
While the ADA does indicate that syringes can be reused, that suggestion is not made to people who have poor personal hygiene, acute concurrent illness, open wounds on the hands, or decreased resistance to infection. In this case, the nurse has assessed that this client has poor hygiene and has difficulty with fine motor skills. This may make it difficult for the client to manipulate the syringe and keep it clean. This client does not meet the criteria for suggesting the reuse of syringes. The nurse should not directly confront the client with the statement about personal hygiene as that would damage the nurse-client relationship. The best answer is to suggest that this client use a new syringe for each injection. |
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A nurse is working on a telemetry unit when one of the clients has a cardiac arrest. The client's spouse is in the room when the code team arrives. Which statement by the nurse is the best, in this situation?
A) "Your spouse's heart stopped. All these people are here to help get it started." B) "Your spouse's physician will be here shortly and explain all of the medication and treatment that your spouse is receiving right now." C) "Is there someone you would like to call? I'm sure this is a scary situation and you may feel more comfortable if someone were with you during this time." D) "I know you're worried about your loved one. I'm sure this is a difficult situation for you. Do you have any questions right now?" |
A
Clarity and brevity provide a message that is simple and clear. In this situation, taking time to explain and/or address all of the spouse's needs and concerns is inappropriate. Not only will the client be unable to process extra information, but the nurse doesn't have time to give long, drawn out explanations about the situation. Dealing with the spouse's fears and concerns right now is not the priority need-the client's emergency situation is. |
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A nurse is working in an acute psychiatric unit. The nurse makes this statement to a co-worker after reviewing a newly admitted client's medical record: "Another client with bipolar disorder. We better be ready for a busy night." This nurse is exemplifying which process of Swanson's theory of caring?
A) Doing for B) Being with C) Enabling D) Knowing |
D
Knowing, according to Swanson, is striving to understand an event as it has meaning in the life of the other. A subdimension of this process is avoiding assumptions. The nurse in this situation made an assumption about clients with bipolar disorder. Being with is being emotionally present to another person. Doing for is providing for others as they would do for themselves if it were at all possible. Enabling is facilitating the other's passage through life transitions and unfamiliar events. |
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A nurse has been working a 12-hour shift in a labor and delivery unit. A client was admitted early in the shift and is now ready to deliver. The client had a difficult labor experience, was worried and anxious throughout, and had physiological problems with blood pressure as well as pain management. The nurse decides to stay until the delivery is over, after having it approved by her manager. This nurse is exhibiting which of the following?
A) Compassion B) Confidence C) Competence D) Conscience |
A
Compassion is being aware of one's relationship to others; sharing their joys, sorrows, pain, and accomplishments; and participating in the experience of another. The nurse exemplifies this by staying until the delivery is over and the birth is accomplished. Competence is having the knowledge, skills, energy, experience, and motivation to respond adequately to others, within the demands of the professional responsibilities. Confidence is the quality that fosters trusting relationships. It is comfort with self, patient, and family. Conscience is focused on morals, ethics, and an informed sense of right and wrong. Awareness of personal responsibility is part of conscience. |
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The nurse is working with a group of elderly clients through a community senior citizens center. Utilizing an understanding of health literacy, the nurse will make sure that:
A) There is ample time for teaching. B) Information given to this group is written at a third-grade level. C) Teaching includes a variety of approaches. D) Information includes pictures. |
A
When working with the elderly population, the nurse must realize that increased time for teaching is necessary because processing of information is slower. Health literacy is the ability to understand, read, and act on health information. Health literacy skills are often limited among certain groups, including older adults, people with limited education, poor or minority populations, and people with limited English proficiency. The average reading ability of many American adults is at the fifth-grade level. Information provided to this group should be large print, on buff-colored paper, and presented at the fifth- to sixth-grade reading level. A variety of approaches should be included regardless of the audience, as people learn by different methods. |
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The nurse is conducting an admission interview. Which of the following indicates that the nurse is attentively listening to the client's explanations?
A) "When was the last time you saw a doctor for this?" B) "I'm sorry, say that again?" C) "Can you explain what your symptoms are like?" D) "Uh-huh," while nodding the head |
D
A nurse can convey attentiveness in listening to clients in various ways. Common responses are nodding the head, uttering "uh-huh" or "mmm," repeating the words the client has used, or saying "I see what you mean." The other options listed are examples of open-ended questions or simply examples of clarifying techniques. |
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A nurse must perform a catheterization on a male client. Which of the zones of proximity would be most appropriate?
A) Public distance B) Personal distance C) Intimate distance D) Social distance |
C
Intimate distance is characterized by body contact and used frequently by nurses when they are required to perform a procedure. Distance in this category is touching to 1-1/2 feet. Personal distance is 1-1/2 to 4 feet and is less overwhelming than intimate distance. Much communication between nurses and clients occurs at this distance, such as sitting with a client, giving medications, or establishing an IV infusion. Social distance is characterized by clear, visual perception of the whole person and is important in accomplishing the business of the day. Public distance requires loud, clear vocalizations and is used for groups of people or in the community for presentations. |
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A client has been diagnosed with diabetes mellitus and must learn how to do his own finger stick blood sugar analysis as part of his treatment. The client has been sullen and uncommunicative since receiving the diagnosis. How can the nurse best increase the client's motivation to learn?
A) Demonstrating the finger stick on the nurse B) Encouraging the client's participation each time the procedure is performed C) Teaching the client's support system how to perform the procedure D) Offering to do the procedure for the client each time it is scheduled |
B
Nurses can increase a client's motivation in several ways, including encouragement of self-direction and independence. Demonstrating the procedure on the nurse may or may not help the client become interested in the learning process, and offering to do the procedure only allows the client's current state of mind to continue. Giving the responsibility to someone else does not encourage the client to learn it. |
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A nurse manager has been dealing with staffing problems and high patient acuity on the unit. The director of nursing has been sensitive to other issues in the past, so the nurse manager decides to approach her with these new concerns. This is an example of which aspect of caring, as proposed by Mayeroff?
A) Courage B) Humility C) Trust D) Knowing |
A
Courage is the sense of going into the unknown, informed by insight from past experiences. Since the manager had prior experience that was positive from the director of nursing, the manager will use this information to address a problem that has not been introduced before. Knowing means understanding the other's needs and how to respond to these needs. Trust involves letting go, to allow the other to grow in his own way and own time. Humility means acknowledging that there is always more to learn, and that learning may come from any source. |
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A client is being discharged from the hospital after a myocardial infarction and has several new medications that have been added to her therapy. She also has been prescribed to follow a low-fat diet. The client states: "I'm never going to understand what to do, when to do it, and why I should be doing all these things." The nurse formulates which of the following diagnoses for this client and her situation?
A) Risk for Myocardial Infarction related to deficient knowledge B) Deficient Knowledge (diet and medication regimen) related to inexperience C) Health-Seeking Behavior related to desire to prevent heart problems D) Noncompliance related to situational factors |
B
The NANDA label Deficient Knowledge is used when the client is seeking health information or when the nurse has identified a learning need, as in this case. The area of deficiency (diet and medication regimen) should always be included in the diagnosis. Health-Seeking Behavior is a diagnostic label used when the client is seeking health information, which is not the case here. Noncompliance is used when the client or caregiver fails to follow a plan, which is too early to tell in this case. Risk for Myocardial Infarction is not a NANDA label. If a risk exists, the label could be Risk for Noncompliance related to deficient knowledge. |
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The student nurse is following a preceptor on the assigned clinical shift. Which of the following behaviors of the nurse would the student interpret as caring?
A) Making sure that all medications and treatments are done on time B) Using aseptic technique when performing a dressing change C) Explaining an invasive procedure to the client, then asking if it is all right to begin the procedure D) Advising the physician that the client wants to speak to him or her prior to a procedure |
C
Caring practice involves connection, mutual recognition, and involvement. It is more than just performing skills adequately or even efficiently. It's a sense that the nurse has made a difference to someone else. Caring means that people, relationships, and things matter. Explaining a procedure, then seeking permission to begin lets the client know that the nurse respects the client as an individual. All other options are examples of appropriate and professional nursing care, but do not address a caring aspect. |
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A nurse educator teaches students about caring nursing practice. Which of the following situations shows that the nurse is able to implement the whole idea of caring?
A) The nurse is a volunteer at church and school events. B) The nurse takes care of his elderly parents as well as providing care to his immediate family. C) The nurse makes lists every morning so the day stays organized and planned. D) The nurse is able to carve out time for a favorite hobby, at least once a week. |
D
It is imperative that nurses attend to their own needs, because caring for self is central to caring for others. As nurses take on multiple commitments to family, work, school, and community, they risk exhaustion, burnout, and stress. None of the other options depict the nurse caring for self, only for other people or trying to stay on top of the many tasks involved in a daily routine. |
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A nurse practitioner emphasizes the importance of the staff engaging in activities that help restore peace and balance between the mind and body. Which of the following might be an appropriate therapy for this?
A) Bike riding B) Reading C) Storytelling D) Cake decorating |
C
Mind-body therapies include imagery, meditation, storytelling, music therapy, and yoga-all of which are complementary therapies that bring balance to thoughts and emotions. Practice of one or more mind-body therapies is an effective self-care strategy to help restore peace and balance. The other three options are not considered mind-body therapies. |
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A nursing student must present a teaching project to the class, using each of Bloom's domains. The student has several activities included in the project. Which of the following activities is an example of the affective domain?
A) Each member of the class must identify two attitudinal changes that have occurred in their lives since beginning their nursing education. B) Members must demonstrate a favorite nursing skill at the end of the class period. C) All members must list the technical skills they've learned. D) Members must read a paragraph about a new clinical trial, summarize the information, and present it to the rest of the class. |
A
The affective domain of Bloom's theory of learning is also known as the "feeling" domain. It includes emotional responses to tasks such as feelings, emotions, interests, attitudes, and appreciations. Listing technical skills and reading or summarizing information is part of the "thinking" domain, which includes knowing, comprehending, application, analysis, synthesis, and evaluation. The psychomotor domain is the "skill" domain and includes hands-on motor skills such as demonstration. |
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At the completion of a teaching session, the nurse must evaluate the effectiveness. In a situation where the client was learning a bandaging technique, the most effective evaluation is which of the following?
A) If the wound heals B) Shared by the nurse and client C) A return demonstration by the client D) When the nurse is satisfied that the client can complete the technique |
B
Both the client and the nurse should evaluate the learning experience. The client can tell the nurse what was helpful and provide a demonstration that shows mastery of the skill. The nurse needs to evaluate whether the client has an understanding of the rationale behind the technique, understands infection control standards, and so on. Using only the return demonstration or focusing on the nurse's satisfaction with the client's performance is one sided. The evaluation is of the bandaging technique, and it may or may not be covering a wound. |
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A new nurse has just started work on an oncology unit. One of the clients has decided to discontinue treatment, even though he understands that his life will be shortened extensively if he does. The nurse is having difficulty with this situation and decides to approach a seasoned nurse for insight and a way to help support this particular client. The nurse is exemplifying which of the following?
A) Honesty B) Hope C) Humility D) Patience |
A
Honesty includes awareness and openness to one's own feelings and genuineness in caring for the other. In this situation, the nurse has her own feelings about what the client should do, but truly wants to provide good care so she seeks out the assistance from someone who may be able to enlighten her. Hope is belief in the possibilities of the other's growth. Humility means acknowledging that there is always more to learn, and that learning may come from any source. Patience enables the other to grow in his own way and time. |
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A client needs discharge teaching regarding the use of a walker before going home. The client's room is small and adjacent to a soda machine and small lounge area. In planning a teaching session, the best thing the nurse can do is:
A) Take the client to a larger area (treatment room, for example) for teaching, then evaluate on the way back to the client's room. B) Make sure a physical therapist is available to do the teaching and can see the client before discharge. C) Wait until just prior to discharge, then do the teaching in the hospital lobby. D) Close the door to the client's room and make sure there is no clutter on the floor before the teaching session begins. |
A
Noise or interruptions can interfere with concentration, whereas a comfortable environment can promote learning. If possible, the client should be out of bed for learning activities. Going to a larger area and then evaluating the learning by watching the client ambulate back to the room would be the best way to implement teaching in this particular situation. The hospital lobby does not provide privacy and can be noisy. There also would be little time to reinforce any teaching needs that might be necessary. Not all hospitals have a physical therapist available to help implement teaching for clients. |
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A nurse is working in a busy intensive care unit. A client is admitted with extensive medical problems and requires a ventilator. Because the nurse already has two other clients assigned to his care, he requests that the nurse manager change assignments so that appropriate attention can be given to this new admission. According to Roach's six C's of caring, which one is the nurse emulating?
A) Commitment B) Confidence C) Compassion D) Conscience |
D
Conscience deals with morals, ethics, and an informed sense of right and wrong as well as an awareness of personal responsibility. This nurse understands the situation of taking on a critically ill client when he is already busy enough and makes an appropriate request for a change in assignment. Compassion is about being aware of one's relationship to others; sharing joys, sorrows, pain, and accomplishments; and participating in the experience of another. Confidence is the quality that fosters trust. It means the nurse has comfort with himself, his clients, and his family. Commitment is a convergence between one's desires and obligations and the deliberate choice to act in accordance with them. |
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A nurse is providing bathing assistance to a young client who was seriously injured and is unable to care entirely for herself. Which of the following actions would be an example of Swanson's doing for process, in her theory of caring?
A) Touching the client's shoulder when she starts to cry B) Seeing the client is uncomfortable with the whole bathing process C) Allowing the client to wash her perineal area D) Drying the client completely |
C
Doing for is providing for the client as she would do for herself if it were possible. Subdimensions of this process include preserving dignity. Drying the client completely, if she is able to do some herself, would not be part of doing for. Sensing that the client is uncomfortable fits in the subdimension of knowing (sensing cues). Touching the client's shoulder is comforting, a subdimension of being with. |
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The nurse is working with a client who has been diagnosed with diabetes and must learn how to self-administer insulin. Which statement regarding feedback will be most beneficial to the client?
A) "You know, there are children who can learn to do this." B) "Maybe it would be better if we taught your spouse to help you with this?" C) "If you don't learn this, you can't be discharged." D) "Next time, dart the needle in your skin, instead of pushing it in." |
D
Feedback should be meaningful to the learner and should support the desired behavior through praise, positively worded corrections, and suggestions of alternative methods. Ridicule or sarcasm can lead to withdrawal from learning as in reminding an adult client that a child can perform the task or not being discharged until the skill is learned. Statements about having somebody else learn the technique may also cause the learner to avoid the teaching moment and to avoid learning the technique altogether. |
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A nurse has been working a 12-hour shift in a labor and delivery unit. A client was admitted early in the shift and is now ready to deliver. The client had a difficult labor experience, was worried and anxious throughout, and had physiological problems with blood pressure as well as pain management. The nurse decides to stay until the delivery is over, after having it approved by her manager. This nurse is exhibiting which of the following?
A) Compassion B) Confidence C) Competence D) Conscience |
A
Compassion is being aware of one's relationship to others; sharing their joys, sorrows, pain, and accomplishments; and participating in the experience of another. The nurse exemplifies this by staying until the delivery is over and the birth is accomplished. Competence is having the knowledge, skills, energy, experience, and motivation to respond adequately to others, within the demands of the professional responsibilities. Confidence is the quality that fosters trusting relationships. It is comfort with self, patient, and family. Conscience is focused on morals, ethics, and an informed sense of right and wrong. Awareness of personal responsibility is part of conscience. |
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A client has been diagnosed with diabetes mellitus and must learn how to do his own finger stick blood sugar analysis as part of his treatment. The client has been sullen and uncommunicative since receiving the diagnosis. How can the nurse best increase the client's motivation to learn?
A) Demonstrating the finger stick on the nurse B) Encouraging the client's participation each time the procedure is performed C) Teaching the client's support system how to perform the procedure D) Offering to do the procedure for the client each time it is scheduled |
B
Nurses can increase a client's motivation in several ways, including encouragement of self-direction and independence. Demonstrating the procedure on the nurse may or may not help the client become interested in the learning process, and offering to do the procedure only allows the client's current state of mind to continue. Giving the responsibility to someone else does not encourage the client to learn it. |
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A client is being discharged from the hospital after a myocardial infarction and has several new medications that have been added to her therapy. She also has been prescribed to follow a low-fat diet. The client states: "I'm never going to understand what to do, when to do it, and why I should be doing all these things." The nurse formulates which of the following diagnoses for this client and her situation?
A) Risk for Myocardial Infarction related to deficient knowledge B) Deficient Knowledge (diet and medication regimen) related to inexperience C) Health-Seeking Behavior related to desire to prevent heart problems D) Noncompliance related to situational factors |
B
The NANDA label Deficient Knowledge is used when the client is seeking health information or when the nurse has identified a learning need, as in this case. The area of deficiency (diet and medication regimen) should always be included in the diagnosis. Health-Seeking Behavior is a diagnostic label used when the client is seeking health information, which is not the case here. Noncompliance is used when the client or caregiver fails to follow a plan, which is too early to tell in this case. Risk for Myocardial Infarction is not a NANDA label. If a risk exists, the label could be Risk for Noncompliance related to deficient knowledge. |
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A nurse is working in the school system with a group of students who are struggling with the death of a classmate. The nurse encourages the students to talk about their friend, bring pictures, and share memories with each other. The nurse also invites the deceased's family to come to the school and visit with their child's classmates. This nurse is working in which of Swanson's processes?
A) Being with B) Knowing C) Doing for D) Enabling |
D
Enabling is facilitating the other's passage through life transitions and unfamiliar events. Being supportive of the students and encouraging them to share and talk about their friend is allowing them to move through the grief process. Enabling also includes supporting, assisting, guiding, and validating. Knowing is striving to understand an event as it has meaning in the life of the other. If this were the case in this situation, the nurse would be asking the students to explain what they are going through, or what it feels like to lose a friend. Being with is being emotionally present to the other. Doing for is providing for others as they would do for themselves if it were at all possible. |
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The nurse enters a client's room and finds that the phone is lying in the client's lap, tissues are wadded up on the bed, and the client's eyes are red and watery. The best response by the nurse is:
A) "Has your doctor been in to talk to you yet?" B) "Can I hang that phone up for you?" C) "Well, it's a beautiful day outside. Let's open the blinds." D) "You look upset. Is there anything you'd like to talk about?" |
D
Nonverbal communication, or body language, often tells the nurse more about what a person is feeling than what is actually said. The interpretation of such observations requires validation with the client. The other options do not address the nonverbal cues. The client's appearance, the phone off the hook, and the tissues lead the nurse to at least consider that perhaps the client had an upsetting phone call. This should be addressed by the nurse. |
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A nurse is working in a neonatal intensive care unit, teaching parents how to care for their tiny babies while they are still in the hospital. Which of the following statements by a parent reflects a readiness to learn?
A) "If my baby is just a little bigger, I'll be able to handle him." B) "You'll give us written instructions before we go home, correct?" C) "I'm so afraid I'll hurt my baby with all these tubes." D) "I want to make sure my spouse is here, in case I don't hear everything that's said." |
D
Readiness to learn is the demonstration of behaviors or cues that reflect a learner's motivation, desire, and ability to learn at a specific time. The client who wants the spouse involved is demonstrating motivation and willingness, but also wants support from the spouse as well. Statements about fear of the situation need to be addressed so the fear will not inhibit the learning process. Wanting to wait until discharge or at least until the baby is older reflects uncertainty and possibly fear and should be addressed before learning can occur. |
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The nurse is working with a group of elderly clients through a community senior citizens center. Utilizing an understanding of health literacy, the nurse will make sure that:
A) There is ample time for teaching. B) Information given to this group is written at a third-grade level. C) Teaching includes a variety of approaches. D) Information includes pictures. |
A
When working with the elderly population, the nurse must realize that increased time for teaching is necessary because processing of information is slower. Health literacy is the ability to understand, read, and act on health information. Health literacy skills are often limited among certain groups, including older adults, people with limited education, poor or minority populations, and people with limited English proficiency. The average reading ability of many American adults is at the fifth-grade level. Information provided to this group should be large print, on buff-colored paper, and presented at the fifth- to sixth-grade reading level. A variety of approaches should be included regardless of the audience, as people learn by different methods. |
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A nurse has been asked to be a member of a hospital's internal review board and evaluate research studies. Which of the following does this nurse most likely possess?
A) Sound ethical knowledge B) Sound aesthetic knowledge C) Sound personal knowledge D) Sound empirical knowledge |
A
Ethical knowing focuses on matters of obligation or what ought to be done and goes beyond simply following the ethical codes of the discipline. Internal review boards review research projects and determine whether they meet sound, ethical standards. The more sensitive and knowledgeable the nurse is to these issues, the more "ethical" the nurse will be. Empirical knowledge is systematically organized into laws and theories for the purpose of describing, explaining, and predicting phenomena. Personal knowledge promotes wholeness and integrity in the personal encounter. Aesthetic knowledge is the art of nursing and is expressed by the individual nurse through his or her creativity and style in meeting the needs of clients. |
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A nurse is evaluating how care is delivered at various hospitals. In the process, the nurse is able to identify a facility where caring in the emergency department is perceived differently than caring in the rehabilitation unit. This type of example reflects whose theory of caring?
A) Boykin and Schoenhofer B) Roach C) Leininger D) Ray |
D
Ray's theory of bureaucratic caring suggests that caring in nursing is contextual and is influenced by the organizational structure. Each unit had its own specific meaning of caring and how it was influenced. Leininger's theory is focused on cultural congruency. Roach focuses on the philosophical concept of caring and proposes that caring is the human mode of being. Boykin and Schoenhofer's theory suggests that caring is a lifelong process, lived moment to moment by the nurse and constantly unfolding. |
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A nurse is presenting teaching sessions to a group of residents in a home for long-term physical rehabilitation. Which of the clients described exhibits the highest motivation?
A) The client who has just moved in and is already waiting for discharge B) A client who is excited to learn about his new prosthesis C) An individual who has been struggling with following nursing directives regarding discharge goals D) A client who has been there the longest and is a great "coach" for newcomers |
B
Motivation is the desire to learn and influences how quickly and to what extent a person learns. It is generally greatest when a person recognizes a need and believes the need will be met through learning. The client who is excited to learn about his prosthesis understands that learning about it will help take his recovery to a high level. Motivation must be experienced by the client, not by someone else (as in being a "coach" for newcomers). Clients who struggle with rules or following prescribed courses of treatment are not motivated to learn the best reason for their particular plan of action. They may be "bucking" the system. The client who is already waiting to go home may be motivated for that, but not to the extent of being ready to learn how to achieve this end. |
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A client has just lost her second baby to preterm complications. The best therapeutic response by the nurse is:
A) "Didn't your doctor advise you about genetic counseling?" B) "I am so sad for you. I'll stay with you for a while if you need to talk." C) "I know how you feel. I have children of my own." D) "Don't be so sad. You can always try again." |
B
Therapeutic communication promotes understanding and is client directed. Nurses need to respond to the feelings expressed by the client. The nurse has no way of knowing how this client feels, and saying so is just insensitive. Asking about genetic counseling implies that the client could have done something to possibly prevent this situation. The client's feelings must be validated, not dismissed ("Don't be so sad, you can always try again"). Sometimes clients need time to deal with their feelings and the best thing the nurse can provide is presence and listening. |
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A nurse is planning a community health education project that deals with organ donation, and the target audience is a group of adults. When following andragogic concepts, the nurse should make sure that the teaching includes which of the following?
A) Information on how this group can influence their children B) Directions about how to become an organ donor C) Written pamphlets D) Past statistics about organ donors |
B
An adult is more oriented to learning when the material is useful immediately, not sometime in the future. For this audience, giving clear directions on how to become an organ donor would be more helpful than past information and future activities like influencing their children. Written information may or may not be helpful, depending on what types of learners are included in the group. |
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A nurse explains to a client that he will need to have a bowel prep before going to his esophagogastroscopy. The nurse should focus on improving which of the following?
A) Intonation B) Clarity C) Pace D) Simplicity |
D
Simplicity includes the use of commonly understood words, brevity, and completeness. A "bowel prep" may be completely meaningless to a client, but telling him that he needs to drink a gallon of laxative-like medication gets the point across better. Esophagogastroscopy is a complicated word. Using words like "small camera looking down your throat into your stomach" will make much more sense to the client. Pace and intonation help indicate interest, anxiety, boredom, or fear-all of which modify the feeling and impact of the message. Clarity and brevity imply that the message is direct and simple-saying precisely what is meant and using the fewest words necessary. |
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A nurse is researching the concept of caring as it relates to specific situations in the clinical area. More specifically, the nurse is interested in caring as it relates to cultural differences. Of the following theorists, which would be of the most help to this nurse researcher?
A) Florence Nightingale B) Madeline Leininger C) Dorothea Orem D) Jean Watson |
B
Leininger's theory of culture care diversity and universality is based on the assumption that nurses must understand different cultures in order to function effectively. Nightingale's theory focuses on the environment. Watson's theory focuses on caring in itself. Orem's theory is about self-care and deficit. |
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A nurse is working in an acute psychiatric unit. The nurse makes this statement to a co-worker after reviewing a newly admitted client's medical record: "Another client with bipolar disorder. We better be ready for a busy night." This nurse is exemplifying which process of Swanson's theory of caring?
A) Doing for B) Being with C) Enabling D) Knowing |
D
Knowing, according to Swanson, is striving to understand an event as it has meaning in the life of the other. A subdimension of this process is avoiding assumptions. The nurse in this situation made an assumption about clients with bipolar disorder. Being with is being emotionally present to another person. Doing for is providing for others as they would do for themselves if it were at all possible. Enabling is facilitating the other's passage through life transitions and unfamiliar events. |
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The nurse is conducting an admission interview. Which of the following indicates that the nurse is attentively listening to the client's explanations?
A) "When was the last time you saw a doctor for this?" B) "I'm sorry, say that again?" C) "Can you explain what your symptoms are like?" D) "Uh-huh," while nodding the head |
D
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A home health client is having difficulty keeping his medication schedule organized. He makes this statement to the nurse at their next visit: "There are so many pills and the names are all confusing to me. I don't even understand what they're for." The nurse should:
A) Have the physician talk to the client about his medications. B) Help the client remember color and size in relationship to dosing time. C) Fill a pill bar and tell the client not to worry, just take the pills according to that system. D) Write out the generic and trade name of all the pills for the client. |
B
Learning is facilitated by material that is logically organized and proceeds from the simple to the complex. This helps the learner comprehend new information, apply it to previous learning, and form new understandings. Naming the pills by color and size and dosing time helps the client move from that level to learning what each medication is for and why he is taking it-simple to complex. Learning generic and trade names is memorization and may not make sense for this client. Filling a pill box or bar is not helping the client learn about his meds, it merely puts them into an order without information. Nurses must rely on their own creativity and resourcefulness-not depend on physician input. |
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The nurse has completed client teaching regarding medication administration. Which of the following statements by the client best illustrates compliance?
A) "I think you should have waited until I was ready to go home. Maybe I'd remember better." B) "I already knew most of what you told me." C) "I'm glad to know about my medications. It makes taking them a lot easier." D) "If I take my medications as prescribed, I'll feel better." |
C
Compliance is best illustrated when the person recognizes and accepts the need to learn, then follows through with appropriate behaviors that reflect learning. Learning about the medications helps the client understand why they're prescribed and improves the possibility for following the prescribed regimen. Statements of prior knowledge do not necessarily lead to compliance and neither does merely following the advice of the health care prescriber. |
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The nurse is conducting an admission interview. Which of the following indicates that the nurse is attentively listening to the client's explanations?
A) "When was the last time you saw a doctor for this?" B) "I'm sorry, say that again?" C) "Can you explain what your symptoms are like?" D) "Uh-huh," while nodding the head |
D
A nurse can convey attentiveness in listening to clients in various ways. Common responses are nodding the head, uttering "uh-huh" or "mmm," repeating the words the client has used, or saying "I see what you mean." The other options listed are examples of open-ended questions or simply examples of clarifying techniques. |
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The nurse is going to be working with a client who has a permanent colostomy and is ready to go home within the next several days. When organizing the teaching/learning experience, the nurse should:
A) Discover what the learner knows before proceeding with further teaching. B) Break up sessions into shortened time periods. C) Make sure the client's spouse is present before the teaching session begins. D) Start from the beginning and proceed through all material. |
A
Nurses should save time in constructing their own teaching sessions and should follow basic guidelines when sequencing the learning experience. The nurse should find out what the learner knows, and then proceed to the unknown. This gives the learner confidence. This information can be elicited either by asking questions or by having the client take a pretest or fill out a form. Going over information already taught and learned isn't practicing good time management for the nurse or the client. Unless the client has attention problems or may be elderly, breaking up the sessions may not be necessary. Having the spouse present is always a good idea, but may not be possible all the time. |
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The nursing diagnosis Health-Seeking Behavior (nutrition and diet) related to desire to improve nutritional intake has been formulated for a client who has decided to change his eating habits to be more nutritionally sound. An appropriate outcome for this client would be which of the following?
A) Client will appreciate the value of using the food guide pyramid. B) Client will be able to lose weight. C) Client will list foods that are nutritionally sound, low fat, and high fiber. D) Client will understand the importance of eating healthy. |
C
Learning outcomes, like client outcomes, must be specific and observable so they can be measured. Words like "understand" or "appreciate" are not measurable and are not observable. "Be able to lose weight" is not specific enough, and with the information given, it is not known if that is really what the client wants to attain. |
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A client is practicing using an incentive spirometer after surgery. The nurse has explained the use, demonstrated how it works, and also given rationale for the client to continue to use this device. By mastering the use of this device, the client will demonstrate learning in which of Bloom's domains?
A) Imitation B) Psychomotor C) Cognitive D) Affective |
B
The psychomotor domain is the "skill" domain and includes motor skills, such as being able to use an incentive spirometer. Cognitive abilities include the "thinking" process that begins with knowing, comprehending, and applying knowledge. The affective domain involves the attitudes or emotional responses and includes feelings, emotions, interests, and appreciations. Imitation is not one of Bloom's domains of learning. |
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A nurse needs to evaluate the effectiveness of a teaching session with a client. Which of the following would provide the best feedback?
A) Therapeutic communication B) Process recording C) Verbal communication D) Client communication |
B
A process recording is a word-for-word account of a conversation. It includes all verbal and nonverbal interactions of both the client and nurse. It would be appropriate to use for evaluating the effectiveness of a teaching session. Client communication, therapeutic communication, and verbal communication are simply types of communication-all of which are helpful in client interactions but do not provide a vehicle for evaluation. |
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A nurse is working on a telemetry unit when one of the clients has a cardiac arrest. The client's spouse is in the room when the code team arrives. Which statement by the nurse is the best, in this situation?
A) "Your spouse's heart stopped. All these people are here to help get it started." B) "Your spouse's physician will be here shortly and explain all of the medication and treatment that your spouse is receiving right now." C) "Is there someone you would like to call? I'm sure this is a scary situation and you may feel more comfortable if someone were with you during this time." D) "I know you're worried about your loved one. I'm sure this is a difficult situation for you. Do you have any questions right now?" |
A
Clarity and brevity provide a message that is simple and clear. In this situation, taking time to explain and/or address all of the spouse's needs and concerns is inappropriate. Not only will the client be unable to process extra information, but the nurse doesn't have time to give long, drawn out explanations about the situation. Dealing with the spouse's fears and concerns right now is not the priority need-the client's emergency situation is. |
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A home health nurse is working with a client who has pulmonary fibrosis. Of the following teaching priorities, which will take the highest priority?
A) Client will be able to do ADLs (activities of daily living) without shortness of breath in 3 days. B) Client will have a positive attitude about the diagnosis by the end of the month. C) Client will have increased activity level by the end of the week. D) Client will be able to set up and administer a nebulizer treatment by the end of the day. |
D
Learning outcomes state the client behavior and are ranked according to priority. Nurses can use theoretical frameworks such as Maslow's hierarchy of needs to establish priorities. In this case, the physiological need of learning how to administer medication takes priority over activity and attitudinal needs. |
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A nurse understands that certain activities are required for a healthy lifestyle. Which of the following is the best example of this?
A) Buying only fat-free foods and allowing absolutely no deviation from this B) Balancing good nutrition and exercise in moderation C) Exercising every day, at least for an hour and a half D) Exercising more on days when feeling "guilty" about a snack |
B
Nutrition and exercise are necessary for a healthy lifestyle, but key words to remember are balance and moderation. Completely avoiding a certain nutrient or keeping the nutritional aspects of one's life so strict that there can be no variance is difficult and indicates more of a compulsive nature than a healthy one. |
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In order to gain the necessary information about a client's situation, the nurse must be able to ask open-ended questions. Which of the following is an example of this type of communication?
A) "What brings you to the hospital?" B) "Does your pain feel better or worse today?" C) "Is there anything I can do for you?" D) "Are you having pain?" |
A
An open-ended question is one that cannot be answered with a simple yes/no or a one-word response. Often they begin with the words What, Describe for me, Explain, or Tell me about.... All other options listed can be answered with one word or a yes/no response. |
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A nurse educator is working with a group of students and demonstrates how to administer an intramuscular injection. The nurse is using which theoretical construct of learning?
A) Pavlov's conditioning response B) Skinner's positive reinforcement C) Thorndike's behaviorism D) Bandura's imitation |
D
Bandura claims that most learning comes from observation and instruction. Imitation is the process by which individuals copy or reproduce what they have observed. Edward Thorndike originally advanced the theory of behaviorism and maintained that learning should be based on the learner's behavior. Skinner and Pavlov focused their work on conditioning behavioral responses to a stimulus that causes the response or behavior. |
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Several nurses have been asked to put together a proposal to help implement a method for self-scheduling. They are given the task of developing a rotation schedule that provides adequate staffing of all shifts. This is an example of which type of group?
A) Self-help group B) Therapy group C) Teaching group D) Task group |
D
The task group is one of the most common types of work-related groups to which nurses belong. The focus of such groups is the completion of a specific task (self-scheduling method). A self-help group is a small, voluntary organization composed of individuals who share a similar health, social, or daily living problem. A teaching group has as its major purpose to impart information to the participants. A therapy group works toward self-understanding, more satisfactory ways of relating or handling stress, and changing patterns of behavior toward health. |
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Compassion is often associated with caring. Of the following, which situation is the best example of compassionate nursing care?
A) The nurse has expert technical skills and has the most experience with critical care. B) The nurse has written procedures and policies in language that is both professional and realistic. C) The nurse takes time to understand the spiritual needs of clients. D) The nurse routinely gives back rubs to clients before they go to sleep. |
C
Attention to spiritual needs is part of compassionate care, particularly in the face of death and bereavement. Technical skills, experience, and writing abilities focus on competency of the nurse. Giving routine back rubs focuses on comfort. All of these are important aspects of nursing care. |
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A student asks the nursing instructor which of the different types of knowledge are important in the clinical area. The best response by the nurse is:
A) "Empirical knowledge. You have to know the physiology of the problem before you decide which interventions to use." B) "Ethical knowledge. Nurses must be able to identify principles and norms, handle conflicts, and be sensitive to sensitive issues." C) "Aesthetic knowledge. A nurse must appreciate the special qualities of each client and the individual situation." D) "A good nurse will have a mix of all four types." |
D
The nurse who practices effectively is able to integrate all types of knowledge to understand situations more holistically. All options are true, but a nurse must possess all four types of knowledge. |
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A nurse is emulating the characteristics of caring, as described by Mayeroff. Which of the following is an example of knowing, in relationship to caring?
A) Seeing that a client is withdrawn and sullen, and spending extra time when providing cares or treatments B) Seeing the connection between the pathophysiology of the cardiac condition and treatment and giving the rationale for certain medications when the client asks C) Getting an extra blanket when the client says he is cold D) Understanding the reason a client's lab values are elevated |
A
Knowing means understanding the other's needs and how to respond to those needs. Sensing that a client is withdrawn and sullen, the nurse knows that spending extra time can sometimes allow the client to feel comfortable in talking about what might be bothering him. Understanding the reason for elevated lab values and the connection between the pathophysiology and treatment of a condition are examples of knowing in the didactic sense. Getting an extra blanket is responding to client needs after being told what those needs are, not sensing or understanding them. |
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During an interaction between a nurse and client, the nurse conveys respect and an attitude that shows the nurse takes the client's opinions seriously. This would happen during which stage of the working phase?
A) Concreteness B) Facilitating and taking action C) Exploring and understanding thoughts and feelings D) Confrontation |
C
The working phase has two major stages: exploring and understanding thoughts and feelings and facilitating and taking action. Confrontation and concreteness are some of the skills required for the first phase. Other skills necessary include empathetic listening and responding, respect, and genuineness. |
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A client is nonverbal and the nurse is implementing strategies to promote communication. Which of the following would be appropriate for the client in this situation?
A) Employing an interpreter B) Using a picture board to facilitate communication C) Making sure that the language spoken is the client's dominant language D) Facing the client when speaking |
B
The client is nonverbal, so speaking en face or using an interpreter or even using the client's dominant language do not address the client's ability to communicate. Only the picture board, of the options listed, would be of assistance. |
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A nursing student was involved in a very difficult situation with a client, the client's family, and a physician. The student felt like she was caught in the middle and wasn't sure how to respond to some of the questions that were being asked about care, treatment, and scheduling. Instead of getting her instructor, the student fielded these questions as best she could. In order to help the student work through this situation, the nursing instructor might advise the student to try which of the following?
A) Music therapy B) Reflection C) Meditation D) Guided imagery |
B
Reflection is thinking from a critical point of view, analyzing why one acted in a certain way and assessing the results of one's actions. Reflection must be personal and meaningful. In this example, it will help the student understand how the situation could have been handled better. Meditation is quieting the mind and focusing it on the present. It helps the individual release fears, worries, and doubts. Guided imagery is a mind-body intervention that uses the power of imagination as a therapeutic tool. Music therapy includes listening, singing, rhythm, and body movement. It is often used to induce relaxation. |
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A client has been sullen and withdrawn since receiving the news of her cancer diagnosis. As the nurse enters the room, the client asks for assistance with a shower. Which comment by the nurse is the most appropriate?
A) "Taking a shower might wash away some of that gloom and doom." B) "If you look better, you might feel better." C) "This is a positive sign. I'll be right back with your supplies." D) "Your spouse will be glad to see that you're feeling better." |
C
How a person dresses or looks may be an indicator of how the person feels. A change in grooming habits may signal that the client is feeling better, but the nurse must be careful in this situation that the focus is not on the client's spouse-but on the client. Telling the client that she might feel better if she looks better and washes away the "gloom and doom" indicates that the client's looks are objectionable. |
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A nurse is working with an elderly male client on a medical unit. Which statement by the nurse is an example of elderspeak?
A) "I think it would be better if you were planning to go to a nursing home after discharge." B) "It's time for us to go to physical therapy." C) "Your children must really love their dad." D) "Your wife must be having trouble adjusting to your illness." |
B
Elderspeak is a speech style, similar to baby talk, that gives a message of dependence and incompetence to older adults. Characteristics of elderspeak include inappropriate terms of endearment, inappropriate plural pronoun use (it's time for us to go to physical therapy), tag questions, and slow, loud speech. Telling the client that he needs to go to a nursing home is just insensitive. Noting that the children love their father or making comments about the wife's adjustments to the illness are not examples of elderspeak, merely the nurse making observations to the client. |
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The student nurse is following a preceptor on the assigned clinical shift. Which of the following behaviors of the nurse would the student interpret as caring?
A) Making sure that all medications and treatments are done on time B) Using aseptic technique when performing a dressing change C) Explaining an invasive procedure to the client, then asking if it is all right to begin the procedure D) Advising the physician that the client wants to speak to him or her prior to a procedure |
C
Caring practice involves connection, mutual recognition, and involvement. It is more than just performing skills adequately or even efficiently. It's a sense that the nurse has made a difference to someone else. Caring means that people, relationships, and things matter. Explaining a procedure, then seeking permission to begin lets the client know that the nurse respects the client as an individual. All other options are examples of appropriate and professional nursing care, but do not address a caring aspect. |
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Assertive communication is an appropriate approach for nurses to use in the clinical area. It decreases the risk for miscommunication with colleagues, clients, and their families. Which of the following would be an example of this type of communication technique when a nurse is addressing a physician?
A) "You need to check the laboratory results of the client in room 423." B) "You should visit with the client's family about the upcoming procedure." C) "I am concerned that the client does not have adequate pain management." D) "We need to be more aware of the situation among the client and the client's family." |
C
An important characteristic of assertive communication includes the use of "I" statements versus "you" statements. "You" statements place blame and put the listener in a defensive position. "I" statements encourage discussion. |
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A nurse manager has been dealing with staffing problems and high patient acuity on the unit. The director of nursing has been sensitive to other issues in the past, so the nurse manager decides to approach her with these new concerns. This is an example of which aspect of caring, as proposed by Mayeroff?
A) Courage B) Humility C) Trust D) Knowing |
A
Courage is the sense of going into the unknown, informed by insight from past experiences. Since the manager had prior experience that was positive from the director of nursing, the manager will use this information to address a problem that has not been introduced before. Knowing means understanding the other's needs and how to respond to these needs. Trust involves letting go, to allow the other to grow in his own way and own time. Humility means acknowledging that there is always more to learn, and that learning may come from any source. |
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The nurse is changing a client's dressing and notes that the wound is obviously infected. The drainage is purulent and has a foul odor. When asked how the wound looks, the nurse says "it looks fine" even though his face tells a different story. This nurse needs to work on which aspect of communication?
A) Timing and relevance B) Credibility C) Clarity and brevity D) Adaptability |
D
Adaptability is adjusting tone of speech and facial expression to match the spoken message. Clearly, if the nurse's face doesn't match his words, the client will identify a problem with the situation. Credibility means worthiness of belief, trustworthiness, and reliability. Timing and relevance affect how the message is taken or heard. Clarity and brevity is preciseness and use of few words. |
