Week 1/2: Practice Multiple Choice Questions

Front 1

Florence Nightingale contributed to the nursing care of soldiers in what war?

Back 1

Crimean War

Hint 1

Ch 1

Front 2

Health promotion is best represented by which of the following activities?

1. Administering immunizations
2. Giving a bath
3. Preventing accidents in the home
4. Performing diagnostic procedures

Back 2

3. Preventing accidents in the home

Health promotion focuses on maintaining normal status without consideration of diseases.

Hint 2

Ch 1

Front 3

Who are America's first two trained nurses?

1. Barton and Wald
2. Dock and Sanger
3. Richards and Mahoney
4. Henderson and Breckinridge

Back 3

3. Richards and Mahoney

Linda Richards was America's first trained nurse.
Mary Mahoney was America's first trained BLACK nurse.

Hint 3

Ch 1

Front 4

A nurse with 2 to 3 years of experience who has the ability to coordinate multiple complex nursing care demands is at which stage of Benner's states of nursing expertise?

1. Stage II, Advanced beginner
2. Stage III, Competent
3. Stage IV. Proficient
4. Stage V, Expert

Back 4

2. Stage III, Competent

Hint 4

Ch 1

Front 5

Which professional organization developed a code for nursing students?

1. ANA
2. NLN
3. AACN
4. NSNA

Back 5

4. NSNA

The National Student Nurses' Association developed the Code of Academic and Clinical Conduct for nursing students in 2001.

Hint 5

Ch 1

Front 6

Which of the following social forces is most likely to significantly impact the future supply and demand for nurses?

1. Aging
2. Economics
3. Science/technology
4. Telecommunications

Back 6

1. Aging

All will impact nursing but not necessarily the supply and demand issue. The aging population contributes to more elders needing specialized care (increasing the demand). Fewer nursing faculty to educate students and fewer nurses practicing because of retirement contribute to the decreasing supply.

Hint 6

Ch 1

Front 7

A female is considering a career as a nurse because of the aspects of caring and nurturing. This individual is using which factor of nursing to base her decision?

1. Women's roles
2. Religion
3. War
4. Economics

Back 7

1. Women's roles

The traditional nursing role has always entailed humanistic caring, nurturing, comforting, and supporting.

Hint 7

Ch 1

Front 8

A RN is considering additional education so that she can provide non-emergent acute care in an ambulatory clinic. This nurse is considering which expanded career role?

1. Nurse anesthetist
2. Clinical nurse specialist
3. Nurse practitioner
4. Nurse administrator

Back 8

3. Nurse practitioner

Nurse practitioners usually deal with non-emergency acute or chronic illness and provide ambulatory care.

Hint 8

Ch 1

Front 9

A nurse is able to provide care to several complex clients and focuses on those items that are the most important. Within which stage of Benner's stages of nursing expertise is this nurse functioning?

1. Stage II, Advanced Beginner
2. Stage III, Competent
3. Stage IV, Proficient
4. Stage V, Expert

Back 9

2. Stage III, Competent

Competent, is able to coordinate multiple complex care demands and focuses on the important aspects of care.

Hint 9

Ch 1

Front 10

The health care organization is having difficulty recruiting and retaining nurses. Which of the following nursing shortage factors is this organization experiencing?

1. Aging workforce
2. Aging population
3. Increased demand for nurses
4. Workplace issues

Back 10

4. Workplace issues

Workplace issues include inadequate staffing, heavy workloads, increased use of overtime, and difficulty recruiting and retaining nurses.

Hint 10

Ch 1

Front 11

Which of the following can be viewed as an effort by an organization to improve the image of nursing?

1. Offering scholarships to high school students to attend nursing school
2. Television commercials showing nurses and doctors providing care together
3. A print advertisement with the statement "Nursing--The hardest job you'll ever love"
4. An ANA-sponsored radio commercial explaining the role of nurses in society today

Back 11

4. An ANA-sponsored radio commercial explaining the role of nurses in society today

The ANA is actively working to improve the image of nursing. The radio commercial will most likely include information to help shape the listener's image of contemporary nursing.

Hint 11

Ch 1

Front 12

A nurse providing care in a well-baby clinic is practicing within which area of nursing practice?

1. Promoting health and wellness
2. Preventing illness
3. Restoring health
4. Providing care to the dying

Back 12

2. Preventing illness

The goal of illness prevention programs is to maintain optimal health by preventing disease. Nursing activities that prevent illness include immunizations, prenatal and infant care, and prevention of sexually transmitted disease.

Hint 12

Ch 1

Front 13

While attending a continuing education seminar, several nurses from different states are discussing their individual state requirements for nursing licensure. Which of the following is the one common thread between all the states' departments of nursing?

1. Protect the public
2. Further nursing education
3. Obtain continuing education contact hours
4. Gain specialization

Back 13

1. Protect the public

Although nurse practice acts differ in various jurisdictions, they all have a common purpose: to protect the public.

Hint 13

Ch 1

Front 14

A new nursing student is disappointed because classes so far are focused on topics such as communication and planning, and she wanted to be a nurse to "provide care." This nursing student is describing which role of the nurse?

1. Teacher
2. Client advocate
3. Caregiver
4. Counselor

Back 14

3. Caregiver

The caregiver role has traditionally included those activities that assist the client physically and psychologically while preserving the client's dignity.

Hint 14

Ch 1

Front 15

A graduate nurse is learning different aspects of the nursing profession while maintaining a sense of responsibility and accountability. The process this nurse is learning is:

1. Case manager
2. Professionalization
3. Socialization
4. Governance

Back 15

2. Professionalization

Professionalization is the process of becoming professional, that is, of acquiring characteristics considered to be professional.

Hint 15

Ch 1

Front 16

An article appears in a nursing journal identifying one area of the United States with unusually high numbers of individuals with type 2 diabetes. This information would be considered:

1. News
2. Health statistics
3. A targeted area of study
4. Demography

Back 16

4. Demography

Demography is the study of population, including statistics about distribution by age and place of residence, mortality (death), and morbidity (incidence of disease). From demographic data, population needs for nursing services can be assessed.

Hint 16

Ch 1

Front 17

Which of the following is an example of continuing education for nurses?

1. Attending the hospital's orientation program
2. Talking with a company representative about a new piece of equipment
3. Completing a workshop on ethical aspects of nursing
4. Obtaining information about the facility's new computer charting system

Back 17

3. Completing a workshop on ethical aspects of nursing

Continuing education refers to formalized experiences designed to enlarge the knowledge or skills of practitioners.

Hint 17

Ch 2

Front 18

Which of the following is a nursing responsibility when critiquing published nursing research?

1. Assume that the research was properly conducted since it has been published
2. Evaluate whether the findings are applicable to the nurse's specific clients
3. Implement the research findings if at least two studies have shown the same results
4. Request the raw data from the researchers so that the nurse can analyze the statistics again

Back 18

2. Evaluate whether the findings are applicable to the nurse's specific clients

Since the primary purpose of research is to improve the quality of client care, the nurse should determine if published research results are applicable to the specific client population.

Hint 18

Ch 2

Front 19

Quantitative research is most appropriate for which of the following studies?

1. A study measuring the effects of sleep deprivation on wound healing
2. A study examining the bereavement process in spouses of clients with terminal cancer
3. A study exploring factors influencing weight control behavior
4. A study examining a client's feelings before and after a bone marrow aspiration

Back 19

1. A study measuring the effects of sleep deprivation on wound healing

Quantitative research collects numerical data. Sleep deprivation can be defined by X number of hours without sleep, and wound healing can be measured by size of wound in relation to the period of time.

Hint 19

Ch 2

Front 20

The use of a qualitative research process is most appropriate for which of the following studies?

1. A study measuring nutrition and weight loss or gain in clients with cancer
2. A study examining oxygen levels after endotracheal suctioning
3. A study examining client reactions to stress after open heart surgery
4. A study measuring differences in blood pressure before, during, and after a procedure

Back 20

3. A study examining client reactions to stress after open heart surgery

This study investigates the subjective experience of stress and would be collected through narrative data.

Hint 20

Ch 2

Front 21

An 85-year-old client in a nursing home tells a nurse, "Because the doctor was so insistent, I signed the papers for that research study. Also, I was afraid he would not continue taking care of me." Which client right is being violated?

1. Right not to be harmed
2. Right to full disclosure
3. Right of privacy and confidentiality
4. Right of self-determination

Back 21

4. Right of self-determination

The right of self-determination means that subjects feel free of constraints, coercion, or any undue influence to participate in a study.

Hint 21

Ch 2

Front 22

A licensed practical nurse can perform which of the following functions?

1. Assess the client's condition
2. Develop a care plan or concept map for the client
3. Provide basic care to the client
4. Evaluate the outcomes of the nursing plan and revise the care accordingly

Back 22

3. Provide basic care to the client

LPNs practice under the supervision of a RN in a hospital, nursing home, rehabilitation center, or home health agency. LPNs usually provide basic direct technical care to clients.

Hint 22

Ch 2

Front 23

Upon successful completion of the NCLEX-RN, the RN is asked to participate in a research study on the coping and adjustment skills of a newly graduated registered nurse. The plan is to use oral, recorded interview with a grounded theory. What type of research study is being conducted?

1. Pilot study
2. Quantitative study
3. Qualitative study
4. Ethnographic study

Back 23

3. Qualitative study

Qualitative study is not linear like quantative research. The intent of qualitative research is to describe and then explain a phenomenon. The technique most often used to collect data for this type of research is interviews.

Hint 23

Ch 2

Front 24

Which of the following activities are examples of how a professional nurse may participate in research? (Select all that apply)

1. Critiquing research for applicable practice
2. Identifying clinical problems suitable for nursing research
3. Encouraging patient participation in a study without informed consent
4. Using research findings in the development of policies, procedures, and practice guidelines for patient care

Back 24

1. Critiquing research for applicable practice
2. Identifying clinical problems suitable for nursing research
4. Using research findings in the development of policies, procedures, and practice guidelines for patient care

All the choices listed are examples of the professional nurse's activities in nursing research. One of the nurse's responsibilities with research is in safeguarding the rights of the client, which include informed consent.

Hint 24

Ch 2

Front 25

A nursing student documents the client's full name and date of birth on the required paperwork for the clinical course and turns it in to the instructor. Which of the following client rights is being violated?

1. Right not to be harmed
2. Right to full disclosure
3. Right to self-determination
4. Right of privacy and confidentiality

Back 25

4. Right of privacy and confidentiality

The nursing student should not document any identifiers or paperwork that would be made public or could cause potential embarrassment to the client. The use of identifiers would violate the right of privacy and confidentiality for the client.

Hint 25

Ch 2

Front 26

Which of the following topics would be considered an in-service educational opportunity?

1. Powerpoint--Tips for Successful Presentations
2. How to Knit a Sweater in 3 Hours
3. Fire Safety
4. New Techniques to Promote Continence in Older Adults

Back 26

3. Fire Safety

Fire safety is a mandatory in-service program for most facilities to meet insurance and safety standards. In-service education programs are administered by employers to increase the knowledge and/or skills of the employees. The term continuing education (CE) refers to formalized experiences designed to enlarge the knowledge or skills of practitioner that keep nurses informed of new techniques and knowledge, assist nurses in attaining expertise in a specialized area of practice, and provide nurses with information essential to nursing practice.

Hint 26

Ch 2

Front 27

An RN manager is making assignments for an RN and LPN on the unit. Which of the following clients would the manager assign to the RN? (Select all that apply)

1. A newly diagnosed diabetic patient who needs education on foot care, diabetic injections, and a 1,800-calorie ADA diet
2. A patient who is 2 days postop and needs assistance with ambulation in the hallway and to the restroom
3. A patient receiving total parental nutrition (TPN)
4. A patient who is undergoing a 24-hour urine collection

Back 27

1. A newly diagnosed diabetic patient who needs education on foot care, diabetic injections, and a 1,800-calorie ADA diet
3. A patient receiving total parental nutrition (TPN)

The most appropriate assignment for the RN would be the newly diabetic patient and the patient receiving TPN due to the complexity of the care. The administration of an IV medication such as TPN needs to be done by an RN since the RN does assessment, while the LPN can collect the data for the lab test and assist with personal care such as toileting and ambulation.

Hint 27

Ch 2

Front 28

What are the reasons for continually revising nursing education curricula? (Select all that apply)

1. New scientific knowledge acquired with new discoveries regarding health
2. Cultural changes that are continuously changing as time progresses
3. New nursing instructors began their career in nursing and continuously change the curriculum
4. Socioeconomic changes that occur in society

Back 28

1. New scientific knowledge acquired with new discoveries regarding health
2. Cultural changes that are continuously changing as time progresses

New scientific knowledge acquired with new discoveries regarding health and cultural changes that are continuously changing as time progresses are two reasons for continually revising nursing education curricula. Disease and treatments evolve as time passes so nurses must keep up to date on all medical breakthroughs.

Hint 28

Ch 2

Front 29

Continuing education is the responsibility of the nurse to keep abreast of ___ and ___ changes and also changes within the nursing profession.

1. Scientific and technological
2. Medical and technological
3. Scientific and human responses
4. Cardiac and neurological

Back 29

1. Scientific and technological

Scientific and technological advances are key factors in keeping abreast of the changing healthcare environment.

Hint 29

Ch 2

Front 30

As a nurse researcher, what is involved in the research project? (Select all that apply)

1. Identifying a research question or problem
2. Writing a thesis paper
3. Collecting data using various means such as computer searches and/or questionnaires
4. Analyzing the data and writing up the results
5. Publishing or presenting the research findings to expand the body of nursing knowledge

Back 30

1. Identifying a research question or problem
3. Collecting data using various means such as computer searches and/or questionnaires
4. Analyzing the data and writing up the results
5. Publishing or presenting the research findings to expand the body of nursing knowledge

The research process involves identifying the problem or question, collecting the data, and analyzing the data.

Hint 30

Ch 2

Front 31

One of the major nursing responsibilities of nursing research that the nurse has is:

1. Encouraging participation of the clients in nursing research
2. Being aware of and advocating on behalf of the cleint's rights
3. Exposing the client to the possibility of injury from the research
4. Pressuring the client into participating in the study

Back 31

2. Being aware of and advocating on behalf of the cleint's rights

All nurses involved in research have a role in safeguarding the client's rights.

Hint 31

Ch 2

Front 32

Which of the following is an example of a primary prevention activity?

1. Antibiotic treatment of a suspected urinary tract infection
2. Occupational therapy to assist a client in adapting his or her home environment following a stroke
3. Nutritional counseling for young adults with a strong family history of high cholesterol
4. Removal of tonsils for a client with recurrent tonsillitis

Back 32

3. Nutritional counseling for young adults with a strong family history of high cholesterol

Actions such as diet modification that help to prevent an illness or detect it in its early stages are primary prevention.

Hint 32

Ch 6

Front 33

Which of the following statements is true regarding types of health care agencies?

1. Hospitals provide only acute, inpatient services
2. Public health agencies are funded by governments to investigate and provide health programs
3. Surgery can only be performed inside a hospital setting.
4. Skilled nursing, extended care, and long-term care facilities provide care for the elderly whose insurance no longer covers hospital stays

Back 33

2. Public health agencies are funded by governments to investigate and provide health programs

City, county, state, or federal government funds pay for health department and agency activities aimed at the global health of the community.

Hint 33

Ch 6

Front 34

In most cases, clients must have a primary care provider in order to receive health insurance benefits. If a client is in need of a primary care provider, it is most appropriate for the nurse to recommend which of the following?

1. Family practice physician
2. Physical therapist
3. Case manager/discharge planner
4. Pharmacist

Back 34

1. Family practice physician

Primary care providers are limited to generalist physicians and advanced practice nurses. In some cases, a gynecologist may qualify as a primary care provider and in other cases not.

Hint 34

Ch 6

Front 35

The most significant method for reducing the ongoing increase in the cost of health care in the United States includes controlling which of the following?

1. Number of children according to the family's income
2. Numbers of uninsured and underinsured persons
3. Number of physicians and nurses nationwide
4. Competition among drug and medical equipment manufacturers

Back 35

2. Numbers of uninsured and underinsured persons

When people have inadequate insurance for health costs, they tend to avoid early and preventive care. This results in eventual use of much more costly resources such as emergency rooms. Methods to provide minimum levels of insurance coverage have been successful in other countries.

Hint 35

Ch 6

Front 36

Choose two frameworks for care that are used for the delivery of nursing care that supports continuity of care and cost-effectiveness:

1. Managed care
2. Nonfunctional method
3. Secondary nursing
4. Team nursing

Back 36

1. Managed care
4. Team nursing

Managed care and team nursing are used as frameworks for care in today's health care system.

Hint 36

Ch 6

Front 37

A client is seeking to control health care costs for both preventive and illness care. Although no system guarantees exact out-of-pocket expenditures, the most prepaid and predictable client contribution would be seen with:

1. Medicare
2. An individual fee-for-service insurance
3. A preferred provider organization (PPO)
4. A health maintenance organization (HMO)

Back 37

4. A health maintenance organization (HMO)

A HMO involves a set monthly membership fee and predictable visit or deductible costs.

Hint 37

Ch 6

Front 38

Nursing's Agenda for Health Care Reform submitted by the ANA included which of the following?

1. Primary health care should be based in acute care hospitals
2. A minimum standard of health care for all persons should be paid for completely with public funds
3. Case management should be focused on clients with enduring health care needs
4. Essential services should be initiated simultaneously to avoid gaps

Back 38

3. Case management should be focused on clients with enduring health care needs

Nursing's Agenda for Healthcare Reform called for case management of those ongoing health care needs.

Hint 38

Ch 7

Front 39

Medicare is divided into two divisions, Part A and Part B. Another plan was added in January 2006. Part D is the:

1. Voluntary prescription drug plan that began in January 2006
2. Voluntary plan that provides partial coverage of outpatient and physician services to those who are eligible
3. Plan section providing insurance toward hospitalization, home care, and hospice care
4. Plan section providing very limited financial coverage to low-income persons

Back 39

1. Voluntary prescription drug plan that began in January 2006

Hint 39

Ch 6

Front 40

Medicare is divided into two divisions, Part A and Part B. Another plan was added in January 2006. Part A is the:

1. Voluntary prescription drug plan that began in January 2006
2. Voluntary plan that provides partial coverage of outpatient and physician services to those who are eligible
3. Plan section providing insurance toward hospitalization, home care, and hospice care
4. Plan section providing very limited financial coverage to low-income persons

Back 40

3. Plan section providing insurance toward hospitalization, home care, and hospice care

Part A is available to people with disabilities and people 65 years and over.

Hint 40

Ch 6

Front 41

A category of the Pew Commission Competencies for Future Practitioners emphasized the need for providers to become skilled in which of the following?

1. Use of technology
2. Budgetary and financial management strategies
3. Traditional clinical approaches
4. Making decisions for incompetent clients

Back 41

1. Use of technology

The Pew Commission identified the need for modern health care providers to be proficient in the use of technology.

Hint 41

Ch 7

Front 42

Medicaid is described as:

1. Voluntary prescription drug plan that began in January 2006
2. Voluntary plan that provides partial coverage of outpatient and physician services to those who are eligible
3. Plan section providing insurance toward hospitalization, home care, and hospice care
4. Plan section providing very limited financial coverage to low-income persons

Back 42

4. Plan section providing very limited financial coverage to low-income persons

Medicaid is a federal public assistance program paid out of general taxes to people who require financial assistance, such as people with low incomes.

Hint 42

Ch 6

Front 43

Medicare is divided into two divisions, Part A and Part B. Another plan was added in January 2006. Part B is the:

1. Voluntary prescription drug plan that began in January 2006
2. Voluntary plan that provides partial coverage of outpatient and physician services to those who are eligible
3. Plan section providing insurance toward hospitalization, home care, and hospice care
4. Plan section providing very limited financial coverage to low-income persons

Back 43

2. Voluntary plan that provides partial coverage of outpatient and physician services to those who are eligible

Part B is voluntary and provides partial coverage of outpatient and physician services to people eligible for Part A.

Hint 43

Ch 6

Front 44

Choose the person(s) eligible for Supplemental Security Income (SSI).

1. Blind
2. Persons not eligible for Social Security
3. Children from low-income families that are covered under Medicaid
4. Anyone over age 65
5. Has recognized disabilities

Back 44

1. Blind
2. Persons not eligible for Social Security
3. Children from low-income families that are covered under Medicaid
5. Has recognized disabilities

SSI is for persons with disabilities, individuals who are blind, or those who may not be eligible for Social Security. The benefits are not restricted to health care costs. Clients often use this money to purchase medicines or to cover costs of extended health care.

Hint 44

Ch 6

Front 45

Which of the following is characteristic of nursing care provided in community-based health?

1. Clients are primarily those with identified illnesses
2. Clients are individuals in groups according to their geographic commonalities
3. Care is paid for by the community as a whole rather than by individuals
4. All clients are case managed

Back 45

2. Clients are individuals in groups according to their geographic commonalities

In community-based health care, clients are cared for according to their geographical locations such as where they live or work, rather than at a major medical center or similar provider setting, which facilitates access. Emphasis is more on client wellness and prevention than on illness and may be paid for through any of the usual forms of insurance or payment (including managed care, private pay, or welfare).

Hint 45

Ch 7

Front 46

What is the name of the classification system that prospective payment systems utilize?

1. Medicare
2. Medicaid
3. State Children's Health Insurance Program (SCHIP)
4. Diagnostic-related groups (DRGs)

Back 46

4. Diagnosis-related groups (DRGs)

DRGs are a prospective payment system limiting the amount paid to hospitals that are reimbursed by Medicare. The system has categories that establish pretreatment diagnosis billing categories.

Hint 46

Ch 6

Front 47

When performing collaborative health care, the nurse implement which of the following?

1. Assume a leadership role in directing the health care team
2. Rely on the expertise of other health care team members
3. Be physically present for the implementation of all aspects of the care plan
4. Delegate decision-making authority to each health care provider

Back 47

2. Rely on the expertise of other health care team members

In collaboration, each member of the team, including the client, participates in sharing ideas and reaching consensus on the best plan of care. The team is generally led by the health care professional most skilled in the client's specific areas of need. Once the plan is established, it may be implemented by any member of the team or a designate at an appropriate time and place. It is not necessarily delegated by the nurse.

Hint 47

Ch 7

Front 48

Third-party reimbursement refers to the insurance company that pays client's (first party) bill to the provider (second party). This component is part of the:

1. Private health insurance plan
2. Diagnostic-related group (DRG)
3. Group health insurance plan
4. Preferred provider organization

Back 48

1. Private health insurance plan

Private health insurance pays either the entire bill or 80% of the costs of health care services.

Hint 48

Ch 6

Front 49

The nurse concludes that effective discharge planning (hospital to home) has been conducted when the client states which of the following?

1. "As soon as I get home, the nurse will come out, look at where I live, and see what kind of care I will need."
2. "All I need are my medications and a ride home. Then I'm all ready for discharge."
3. When I visit my doctor in 10 days, they will show me how to change my bandages."
4. "I have the phone numbers of the home care nurse and the therapist who will visit me at home tomorrow."

Back 49

4. "I have the phone numbers of the home care nurse and the therapist who will visit me at home tomorrow."

Effective discharge planning would have included an assessment of home care needs prior to the client leaving the hospital. The kind of care is determined before the client leaves the current setting. That is why it is called discharge "planning." Following a thorough assessment, the client would be taught self-care strategies and a basic plan of care for the coming days.

Hint 49

Ch 7

Front 50

Prepaid group plans for insurance include:

1. Medicare and Medicaid
2. Blue Cross and Blue Shield
3. HMOs, PPOs, PPAs, IPAs, and PHOs
4. Social Security and Supplemental Security Income

Back 50

3. HMOs, PPOs, PPAs, IPAs, and PHOs

Hint 50

Ch 6

Front 51

A large disaster in a community resulted in the destruction of many family homes and many individuals were injured. The assistance of community health nurses and home health nurses are needed. The home health nurse is most likely to perform which of the following?

1. Provide for a safe water supply
2. Monitor for communicable diseases
3. Establish communication and support systems
4. Assess and treat individual clients

Back 51

4. Assess and treat individual clients

The home health nurse more commonly works with single persons or families at one time--addressing their particular needs that may be similar to or different from those of others.

Hint 51

Ch 7

Front 52

What is an example of health promotion?

1. Immunizing children against chickenpox
2. Caring for a dying client
3. Assisting a stroke victim to highest rehabilitation possible
4. Secondary prevention

Back 52

1. Immunizing children against chickenpox

Hint 52

Ch 6

Front 53

The competencies necessary for collaboration between health care providers include:

1. Mutual respect, trust, and negotiation
2. Communication skills, trust, and decision making
3. Negotiation, conflict management, and mutual respect
4. Conflict management, trust, and decision making

Back 53

2. Communication skills, trust, and decision making

This means a collegial working relationship with another health care provider in the provision of client care. It requires the discussion of client diagnosis and cooperation in the management and delivery of care.

Hint 53

Ch 7

Front 54

As a nurse collaborator, the nurse will perform these actions:

1. Share personal expertise with other nurses and elicit the expertise of others to ensure quality client care
2. Seek opportunities to collaborate with and within professional organizations
3. Offer expert opinions on legislative initiatives related to health care
4. Collaborate with other health care providers and consumers on health care legislation to best serve the needs of the public

Back 54

1. Share personal expertise with other nurses and elicit the expertise of others to ensure quality client care

The nurse collaborator shares personal expertise with other nurses and elicits the expertise of others to ensure quality client care. The nurse also develops a sense of trust and mutual respect with peers and recognizes their unique contributions.

Hint 54

Ch 7

Front 55

Which roles, besides, educator, does the nurse need to have in community-based nursing in order to meet the challenges?

1. Manager, collaborator, advocate, and clinician
2. Advocate, clinician, decision maker, and empowerment
3. Advocate to heighten degree of awareness of being a rural nurse, advocate, and enforcer
4. Enforcer of health policies, clinician, and team nurse

Back 55

1. Manager, collaborator, advocate, and clinician

The nurse role is diverse and comprehensive in various practice settings. The nurse providing care to individuals, families, groups, and the general community must be flexible in order to accomodate the various locations. The community may include schools, rural areas, public health, home health, camp nursing, parish nursing, and occupational health sites.

Hint 55

Ch 7

Front 56

When does discharge planning begin for a client?

1. Prior to discharge
2. At admission
3. Two days after admission
4. Two hours before discharge

Back 56

2. At admission

Discharge planning needs to begin when a client is admitted to an agency, especially in hospitals where stays are considerably shortened. Effective discharge planning involves ongoing assessment to obtain comprehensive information about the client's ongoing needs and nursing care plans to ensure those needs are met.

Hint 56

Ch 7

Front 57

While doing a home health appraisal, the home health nurse notes the following conditions. Which are potential hazards? (Select all that apply)

1. Adequate lighting in the rooms, hallways, stairways, and night lights in the hallways
2. Stairs without handrails
3. Grab bars near toilet and tub
4. Unsecured throw rugs
5. No fire alarm or extinguisher
6. Running water and electricity

Back 57

2. Stairs without handrails
4. Unsecured throw rugs
5. No fire alarm or extinguisher

A home health hazard appraisal includes all areas listed, including self-care barriers, lack of wheelchair access to bathroom or home, lack of space for required equipment, or other hazards identified by the nurse.

Hint 57

Ch 7

Front 58

Which of the following populations would possibly be identified before discharge as needing a referral to a long-term nursing facility?

1. An elderly client who has no caregivers to provide the necessary oversight of care
2. A child who has had an uncomplicated removal of the tonsils
3. A mother who delivered a 7-pound baby vaginally the previous day
4. A client who has a well-healed surgical wound to the abdomen

Back 58

1. An elderly client who has no caregivers to provide the necessary oversight of care

The elderly client without caregivers would need a referral to meet his or her health care needs. The nurse would assess the client's personal and health data; ability to perform the activities of daily living; any physical, cognitive, or other functional limitations; adequacy of financial resources; and any other factors.

Hint 58

Ch 7

Front 59

What is the major responsibility of community nursing?

1. Primary health care in the event of an emergency
2. Health promotion and disease prevention
3. Being dependent in their practice
4. Practices in an institutional setting

Back 59

2. Health promotion and disease prevention

Community health nursing involves continuous primary health care, provides autonomy to nurses in their practice, utilizes interdisciplinary approaches, and involves other factors.

Hint 59

Ch 7

Front 60

Choose the correct responses that identify a healthy community.

1. The members are aware that they belong to and participate in a community
2. There are closed channels of communication that do not allow information to flow among the citizens
3. Legitimate and effective ways to settle disputes that arise within the community exist
4. A decreased level of wellness in promoted among some of its members

Back 60

1. The members are aware that they belong to and participate in a community
3. Legitimate and effective ways to settle disputes that arise within the community exist

Communication needs to flow among all the citizens of a healthy community. In addition, health promotion must be promoted among all the members of the community.

Hint 60

Ch 7

Front 61

One community-based program is parish nursing; identify one of the following roles that the parish nurse may perform.

1. Establish an abuse program
2. Serve as an outreach coordinator
3. Serve as faith healer
4. Serve as a personal health counselor

Back 61

4. Serve as a personal health counselor

The parish nurse serves as a personal health counselor to the community within the congregation.

Hint 61

Ch 7

Front 62

One group that benefits from having advanced practice nurses within the community is:

1. Institutionalized persons
2. School-age children
3. Homeless persons
4. Socially adept individuals

Back 62

3. Homeless persons

The homeless population has benefited from advanced practice nurses being in the community. Such nurses provide easier access to health care.

Hint 62

Ch 7

Front 63

A student nurse is caring for a 72-year-old client with Alzheimer's disease who is very confused. The most appropriate communication strategy should include which of the following?

1. Written directions for bathing
2. Speaking very loudly
3. Gentle touch while providing ADLs
4. Flat facial expression

Back 63

3. Gentle touch while providing ADLs

Nonverbal, gentle touch is an important tool; overstimulation may affect the client in a negative way.

Hint 63

Ch 26

Front 64

Using the phases of the helping relationship as a framework, place the following descriptions in the correct sequence.

1. After introductions, the nurse asks, "What plans do you have for the upcoming holiday weekend?"
2. The nurse states, "It sounds like you are concerned about the possible complications of having diabetes. What would be the most helpful for you at this time?"
3. The nurse reads in the medical history that the client was diagnosed with diabetes 1 week ago.
4. The nurse states, "When we met, you knew very little about diabetes and now you are able to use your new information and apply it to your own personal situations."

Back 64

3. The nurse reads in the medical history that the client was diagnosed with diabetes 1 week ago.
1. After introductions, the nurse asks, "What plans do you have for the upcoming holiday weekend?"
2. The nurse states, "It sounds like you are concerned about the possible complications of having diabetes. What would be the most helpful for you at this time?"
4. The nurse states, "When we met, you knew very little about diabetes and now you are able to use your new information and apply it to your own personal situations."

Hint 64

Ch 26

Front 65

The nurse who uses appropriate therapeutic listening skills will display which of the following behaviors? (Select all that apply)

1. Absorb both the content and the feeling the client is conveying
2. Presume an understanding of the clients needs
3. Adopt an open professional posture
4. React quickly to the message

Back 65

1. Absorb both the content and the feeling the client is conveying
3. Adopt an open professional posture

These are listening behaviors; the others are barriers to listening.

Hint 65

Ch 26

Front 66

A nurse tells a client who is struggling with cancer pain, "It is normal to feel frustrated about the discomfort." Which of the following is most representative of the skills associated with the working phase of the helping relationship?

1. Respect
2. Genuineness
3. Concreteness
4. Confrontation

Back 66

1. Respect

Respect is correct because the nurse is validating the client's feelings.

Hint 66

Ch 26

Front 67

A depressed client who has not bathed or dressed in clean clothes today is reading the lunch menu but is unable to make a decision. Which of the following would be the most appropriate nursing diagnosis for this client?

1. Anxiety
2. Powerlessness
3. Chronic Low Self-Esteem
4. Social Isolation

Back 67

2. Powerlessness

Because anxiety and low self-esteem precede powerlessness which results in indecisiveness; it is the most correct answer; nursing management always deals with the client's current display of needs.

Hint 67

Ch 26

Front 68

After being admitted for emergency surgery, an 80-year-old client has just returned to the room from PAR (post-anesthesia room). Which nursing interventions are most likely to facilitate effective communication with this client? (Select all that apply)

1. Ask the client, "Do you know where you are?"
2. Ask the client or support person about visual or learning problems.
3. Inform the client and support person(s) about events likely to occur during the next 2 hours.
4. Provide the client with instructions about discharge

Back 68

2. Ask the client or support person about visual or learning problems.
3. Inform the client and support person(s) about events likely to occur during the next 2 hours.

Assessing possible visual or hearing problems allows the nurse to provide appropriate interventions (i.e., inserting hearing aid). Communicating what will be occurring at a stressful time helps the client feel more secure and can reduce anxiety.

Hint 68

Ch 26

Front 69

The nurse is communicating with a well-oriented older adult client in a long-term care setting. Which statement best reflects respectful and caring communication?
1. "Are we ready for our shower?"
2. "It's time to go to the dining room, honey."
3. "Are you comfortable, Mrs. Smith?"
4. "You would rather wear the slacks, wouldn't you?"

Back 69

3. "Are you comfortable, Mrs. Smith?"

All the other terms are forms of elder speak.

Hint 69

Ch 26

Front 70

The client made the following statement to the nurse, "My doctor just told me that he cannot save my leg and that I need to have an above-the-knee amputation." Which of the following responses by the nurse is most appropriate?

1. "Dr. Jones is an excellent surgeon."
2. "Are you in pain?"
3. "If I were you, I'd get a second opinion."
4. "Tell me more..."

Back 70

4. "Tell me more..."

This is a therapeutic technique using an open-ended question that allows the client to elaborate.

Hint 70

Ch 26

Front 71

The nurse is communicating with a primary care provider about medical interventions prescribed for a client. Which of the following statements is most representative of a collaborative nurse-physician relationship?

1. "That new medication you prescribed for Mr. Black is ineffective."
2. "I am worried about Mr. Black's blood pressure. It is not decreasing even with the new antihypertensives medication."
3. "Can we tallk about Mr. Black?"
4. "Excuse me doctor. I think we need to talk about Mr. Black's blood pressure."

Back 71

2. "I am worried about Mr. Black's blood pressure. It is not decreasing even with the new antihypertensives medication."

This uses an "I" statement which is assertive communication and is clear and direct. The message includes only the necessary information.

Hint 71

Ch 26

Front 72

The nurse asks the client, "What do you fear most about your surgery tomorrow?" This is an example of which of the following communication techniques?

1. Providing general leads
2. Seeking clarification
3. Presenting reality
4. Summarizing

Back 72

1. Providing general leads

It encourages the client to verbalize and choose the topic of conversation.

Hint 72

Ch 26

Front 73

The nurse is using active listening skills, building rapport, and providing a nonjudgmental attitude and non-reactive behaviors. Based on this information, which populations is the nurse communicating with? (Select all that apply)

1. Infants
2. School-age children
3. Adolescents
4. Toddlers

Back 73

2. School-age children
3. Adolescents
4. Toddlers

The ability to communicate is related to the development of thought processes, the presence of intact sensory and motor systems, and the extent and nature of an individual's opportunities to practice communication skills. The nurse needs to develop a rapport with each group in order to effectively communicate.

Hint 73

Ch 26

Front 74

While assessing a postoperative client for pain, the nurse notices the client is holding the surgical site and making facial grimaces. However, the client states that she is not hurting. What part of the communication process is most important in this scenario?

1. Sender
2. Receiver
3. Message
4. Feedback

Back 74

3. Message

The sender is a person or group who wishes to convey a message to another. The receiver is the listener. The second component is the message itself. Feedback is the message that the receiver returns to the sender.

Hint 74

Ch 26

Front 75

The nurse is administering an enema to a client with a questionable gastrointestinal blockage. The nurse is in what type of personal space for the client?

1. Intimate
2. Personal
3. Social
4. Public

Back 75

1. Intimate

Intimate-distance communication is characterized by body contact and heightened sensations of body heat and smell.

Hint 75

Ch 26

Front 76

The nurse makes direct eye contact and has a pleasant expression on her face when changing a client's colostomy bag. The nurse tells the client, "The colostomy looks good." What type of communication is the nurse demonstrating?

1. Nonverbal communication
2. Process recording
3. Congruent communication
4. Noncongruent communication

Back 76

3. Congruent communication

Congruent communication is when the words and actions are focused in the same direction.

Hint 76

Ch 26

Front 77

The nurse is participating in a self-help group on women's health. What is one of the main functions of the nurse's role?

1. Participate as a member of the self-help group when appropriate
2. Give information to the group in order to teach about women's health
3. Buffer the stress within the group
4. Lend the group an air of professionalism

Back 77

1. Participate as a member of the self-help group when appropriate

A self-help group is a small, voluntary organization.

Hint 77

Ch 26

Front 78

A client expresses anxiety about a surgical procedure. What would be the most appropriate therapeutic communication technique to use in this situation? (Select all that apply)

1. Using open-ended questions
2. Probing and rejecting the comment made by the client
3. Restating or paraphrasing the comment made by the client
4. Offering unwanted reassurance

Back 78

1. Using open-ended questions
3. Restating or paraphrasing the comment made by the client

Therapeutic communication techniques facilitate communication and focus on the client's concerns.

Hint 78

Ch 26

Front 79

In which of the following situations would using the therapeutic communication of "touch" be appropriate?

1. When a family member is making inappropriate comments to the nurse, touch is appropriate
2. Touch is never appropriate in the nursing profession
3. When an upset spouse is alone and the client has just expired, touch is appropriate
4. When a young male client asks a young student nurse for a hug, touch is appropriate

Back 79

3. When an upset spouse is alone and the client has just expired, touch is appropriate

There are situations when appropriate use of touch reinforces caring feelings. However, the nurse must be sensitive to the differences in attitudes and practices of clients and self.

Hint 79

Ch 26

Front 80

What type of behaviors is the client exhibiting if he states that he will not need assistance with any aspect of his personal care?

1. Resistant behaviors
2. Introductory behaviors
3. Preinteraction behaviors
4. Trusting behaviors

Back 80

1. Resistant behaviors

During the initial parts of the introductory phase, the client may display some resistant behaviors that inhibit involvement, cooperation, or change.

Hint 80

Ch 26

Front 81

A primary nurse developed a contract with a newly admitted client. Which phase of the helping relationship is the nurse involved in?

1. Preinteraction phase
2. Introductory phase
3. Working phase
4. Termination phase

Back 81

2. Introductory phase

The introductory phase is when the client and nurse formulate the contract.

Hint 81

Ch 26

Front 82

The older client asks the physician is she needs to move into an assisted living facility instead of living alone now that she is old. The physician responded by telling the client that if she were his mother, he would tell her to go into the assisted living facility because her meals would be cooked for her and she would not have to clean anything. The physician was demonstrating what type of barrier to communication?

1. Stereotyping
2. Being defensive
3. Challenging
4. Giving common advice

Back 82

4. Giving common advice

Hint 82

Ch 26

Front 83

A client has severe arthritis, yet she still works 40 hours a week and takes care of her family. This is an example of which health model?

1. Clinical model
2. Adaptive model
3. Role performance model
4. Eudemonistic model

Back 83

3. Role performance model

The role performance model identifies health as the ability of an individual to fulfill societal roles, such as performing his or her own work.

Hint 83

Ch 17

Front 84

In the health model, illness is a condition that prevents self-actualization.

1. Clinical model
2. Adaptive model
3. Role performance model
4. Eudemonistic model

Back 84

4. Eudemonistic model

The eudemonistic model incorporates a comprehensive view of health. Health is seen as a condition of actualization or realization of a person's potential. In this model the highest aspiration of people is fulfillment and complete development, which is actualization. Illness, in this model, is a condition that prevents self-actualization.

Hint 84

Ch 17

Front 85

Osteoporosis and autoimmune diseases are examples of what type of biologic dimension that influences a person's health?

1. Genetic makeup
2. Gender
3. Age
4. Developmental levels

Back 85

2. Gender

Gender influences the distribution of disease. Certain acquired and genetic diseases are more common in one sex than in the other.

Hint 85

Ch 17

Front 86

During the first years of life, infants lack physiologic and psychological maturity, so their defenses against disease are lower. This is an example of what type of biologic dimension that influences a person's health?

1. Genetic makeup
2. Gender
3. Age
4. Developmental levels

Back 86

4. Developmental levels

Developmental level has a major impact on health status.

Hint 86

Ch 17

Front 87

The impact of illness on an individual may cause:

1. The client to become dependent on others
2. The client to have role changes within the family
3. The client to become more outgoing and friendly
4. The client's self-esteem to greatly increase

Back 87

2. The client to have role changes within the family

Emotional responses to stress affect body function. For example, a student who is extremely anxious before a test may experience urinary frequency and diarrhea. A person worried about the outcome of surgery or about the behavior of a teenager may chain-smoke. Prolonged emotional stress may increase susceptibility to organic disease or precipitate it. Emotional distress may influence the immune system through central nervous system and endocrine alterations.

Hint 87

Ch 17

Front 88

A nursing student is instructing a female client on healthy lifestyle choices. What are the correct examples of healthy lifestyle choices? (Select all that apply)

1. Tobacco use of 1 pack per day
2. Exercising 3-4 days per week for 1 hour
3. Regular dental checkup
4. Seat belt use
5. Overeating

Back 88

2. Exercising 3-4 days per week for 1 hour
3. Regular dental checkup
4. Seat belt use

Lifestyle choices refer to a person's general way of living that are influenced by sociocultural factors and personal characteristics. Lifestyle choices have either a positive or negative effect on health.

Hint 88

Ch 17

Front 89

A client who was grossly overweight decided to lose weight in order to feel better about himself and become healthier. What health belief model could the nurse use to assist the client?

1. Health locus of control model
2. Rosenstock's health belief model
3. Becker's health belief model
4. Pender's health belief model

Back 89

1. Health locus of control model

Hint 89

Ch 17

Front 90

A client reports that she has been practicing yoga for the past 2 years in order to reduce stress and increase muscle flexibility. What part of wellness is this client participating in?

1. Physical and emotional
2. Physical and social
3. Social and emotional
4. Intellectual and emotional

Back 90

2. Physical and social

Physical wellness is the ability to carry out daily tasks and practice positive lifestyle habits. Social wellness is the ability to interact successfully with people and within the environment.

Hint 90

Ch 17

Front 91

The nurse is attempting to instruct a chronic obstructive pulmonary disease client on the benefits of not smoking, yet the nurse reeks of cigarette smoke and admits that she also smokes one pack a day. What might be a factor in the client's refusal to quit smoking at this time?

1. The client is distressed about quitting the habit of smoking
2. The nurse is not modeling healthy lifestyle choices
3. The perceived benefits of not smoking are inconclusive at this time
4. The client's cultural heritage demands that he smoke two packs of cigarettes per day

Back 91

2. The nurse is not modeling healthy lifestyle choices

Many factors influence adherence to healthy practices. Role modeling by the nurse is a very important aspect when teaching clients about healthier choices.

Hint 91

Ch 17

Front 92

Diabetes mellitus is an example of:

1. Acute illness
2. Adherence
3. Chronic illness
4. Exacerbation

Back 92

3. Chronic illness

A chronic illness is one that lasts for an extended period, usually 6 months or longer, and often for the person's life.

Hint 92

Ch 17

Front 93

The nurse is assessing the sputum characteristics of a client with pneumonia. What are the senses that the nurse may use in the assessment of the sputum? (Select all that apply)

1. Vision
2. Smell
3. Hearing
4. Touch

Back 93

1. Vision
2. Smell

The color of the sputum and any smell associated with it may be important cues to the disease process.

Hint 93

Ch 11

Front 94

What are two coping mechanisms that clients may exhibit during hospitalization?

1. Micromanaging and/or anger
2. Macromanaging and/or anger
3. Misery and/or aggression
4. Anger and/or mismanagement

Back 94

1. Micromanaging and/or anger

When a person is hospitalized, he or she loses control over even the most basic decisions of daily life. Some coping mechanisms to deal with this sense of loss may be anger, or micromanaging the few things over which the person does have control.

Hint 94

Ch 11

Front 95

During the process of data collection, the nurse must be cognizant of the different cultural aspects in health care. In the interview phase, what should the nurse consider that might have a cultural aspect?

1. Time of the interview
2. Setting of the interview
3. Distance between nurse and client
4. Seating arrangement

Back 95

3. Distance between nurse and client

The distance between the interviewer and interviewee should be neither too small nor too great because people feel uncomfortable when talking to someone who is too close or too far away.

Hint 95

Ch 11

Front 96

What is an example of an open-ended question that the nurse may use in the interview process?

1. "What medication did you take today?"
2. "What surgeries have you had in the past?"
3. Are you a student at the local college?"
4. "How have you been feeling lately?"

Back 96

4. "How have you been feeling lately?"

Open-ended questions are those questions that allow the interviewee to do the talking. They are easy to answer and nonthreathening.

Hint 96

Ch 11

Front 97

What is the name of the head-to-toe approach that usually begins the nurse physical examination?

1. Review of systems
2. Screening examination
3. Cephalocaudal
4. Caudal approach

Back 97

3. Cephalocaudal

The cephalocaudal or head-to-toe approach begins the examination at the head; progresses to the neck, thorax, abdomen, and extremities; and ends at the toes.

Hint 97

Ch 11

Front 98

What framework is based on 11 functional health patterns and collects data about dysfunctional and functional behavior?

1. Orem's self-care model
2. Gordon's functional health patterns
3. Roy's adaptation model
4. The wellness model

Back 98

2. Gordon's functional health patterns

Gordon's functional health framework collects data about functional and dysfunctional behaviors.

Hint 98

Ch 11

Front 99

After completing the health history and the physical assessment, the nurse identifies discrepancies in the information. What is this process called?

1. Assessing
2. Diagnosing
3. Planning
4. Evaluating

Back 99

2. Diagnosing

Diagnosing is analyzing data; identifying health problems, risks, and strengths; and formulating diagnostic statements.

Hint 99

Ch 11

Front 100

A client presents to the emergency department with complaints of chest pain. The nurse takes the client's vital signs. The nurse is implementing which phase of the nursing process?

1. Assessment
2. Diagnosis
3. Planning
4. Implementation

Back 100

1. Assessment

The first step in the nursing process is assessment, the process of collecting data.

Hint 100

Ch 11

Front 101

The nurse reassesses a client's temperature 45 minutes after administering acetaminophen. This is an example of what type of an assessment?

1. Ongoing
2. Intermittent
3. Terminal
4. Routine

Back 101

1. Ongoing

The ongoing evaluation is done while or immediately after implementing the nursing intervention.

Hint 101

Ch 11

Front 102

The nurse is measuring the drainage from a Jackson Pratt drain. Which of the following should the nurse consider as objective data?

1. The client is complaining of abdominal pain
2. The drainage measurement is 25 mL
3. The client stated, "I did not empty the drain."
4. The client stated that he has a pain level of 5

Back 102

2. The drainage measurement is 25 mL

Data that is measurable is objective data.

Hint 102

Ch 11

Front 103

A client reports that he believes he will "never kick the habit" of smoking because he has tried before and failed. Using the transtheoretical model (TTM), what stage of health behavior change is the client functioning in?

1. Preparation stage
2. Contemplation stage
3. Termination stage
4. Action stage
5. Precontemplation stage
6. Maintenance stage

Back 103

5. Precontemplation stage

In this stage, the person does not change his/her behavior in the next 6 months. The client tends to avoid reading, talking, or thinking about his/her high-risk behaviors.

Hint 103

Ch 16

Front 104

Identify which of the following is the most basic type of health promotion activity. (Select all that apply)

1. A billboard promoting abstinence to prevent STDs and unplanned pregnancies
2. A wellness assessment program
3. An environment control program about pesticide uses
4. A nurse who models healthy lifestyle behaviors
5. A school of nursing that is holding a blood pressure fair

Back 104

1. A billboard promoting abstinence to prevent STDs and unplanned pregnancies
5. A school of nursing that is holding a blood pressure fair

Information dissemination is the most basic type of health promotion program. Examples are billboards, posters, brochures, newspapers, books, and health fairs. It raises the level of knowledge and awareness of individuals and groups about healthy behaviors.

Hint 104

Ch 16

Front 105

The nurse refers a new below-the-knee (BKA) amputation client to a support group for amputees. This is an example of what type of prevention?

1. Primary
2. Secondary
3. Tertiary
4. Terminal

Back 105

3. Tertiary

Tertiary care begins after an illness, when a disability is fixed, stabilized, or determined to be irreversible. The focus is to assist rehabilitation and restore clients to the highest level of functioning.

Hint 105

Ch 16

Front 106

The nurse is providing health education about injury and poisoning prevention to a group of young mothers at a health fair. What type of prevention in the nurse conducting?

1. Primary
2. Secondary
3. Tertiary
4. Limited

Back 106

1. Primary

Primary prevention is generalized health promotion and specific protection against diseases or specific accidents targeted to a specific group. This intervention precedes disease or dysfunction and is applied to generally healthy individuals or groups.

Hint 106

Ch 16

Front 107

A client had surgery for GI problems and required a colostomy from the surgery. What type of preventative care would this client need at this stage?

1. Primary
2. Secondary
3. Tertiary
4. Limited

Back 107

3. Tertiary

Tertiary prevention begins after an illness, when a defect or disability is fixed, stabilized, or determined to be irreversible. Its focus is to help the client rehabilitate and be restored to an optimum level of functioning within the constraints of disability.

Hint 107

Ch 16

Front 108

A school nurse is teaching a group of seniors about self-examination techniques for breast and testicular cancer in their health class. What type of health care prevention is the school nurse teaching?

1. Primary
2. Secondary
3. Tertiary
4. Limited

Back 108

1. Primary

Primary prevention is generalized health promotion and specific protection against diseases or specific accidents targeted to a specific group. This intervention precedes disease or dysfunction and is applied to generally healthy individuals or groups.

Hint 108

Ch 16

Front 109

Pender's health promotional model would benefit which of the following clients? (Select all that apply)

1. An active 21-year-old client who does not smoke or drink alcohol
2. A 50-yr-old client who exercises four times a week
3. A 32-year-old who has yearly breast exams and other routine health screenings
4. An overweight 29-year-old who engages in risky behaviors

Back 109

1. An active 21-year-old client who does not smoke or drink alcohol
2. A 50-yr-old client who exercises four times a week
3. A 32-year-old who has yearly breast exams and other routine health screenings

All of the individuals listed are engaging in health promotion activities.

Hint 109

Ch 16

Front 110

A client has complete confidence that she has learned health behaviors that will enable her to maintain her current health status by exercising three to five times a week, monitoring her dietary intake, and by no longer engaging in risky behaviors. What stage of health behavior change is this client experiencing?

1. Maintenance
2. Action
3. Preparation
4. Termination

Back 110

4. Termination

This stage is when the individual has complete confidence that the problem is no longer a temptation or threat.

Hint 110

Ch 16

Front 111

The client is attending Alcoholics Anonymous (AA) meetings for support to assist in remaining sober. It is anticipated that the client will remain in this group for several years. What stage of health behavior change is this client experiencing?

1. Maintenance
2. Action
3. Preparation
4. Termination

Back 111

1. Maintenance

This stage is when the person is striving to prevent relapse by integrating newly adopted behaviors into his or her lifestyle.

Hint 111

Ch 16

Front 112

Who is responsible for developing health promotion plans?

1. Physician
2. Family
3. Client
4. Nurse

Back 112

3. Client

The client develops his or her own plan with some assistance from the other team members as needed.

Hint 112

Ch 16

Front 113

What are two driving forces for the immense need for culturally focused nursing care? (Select all that apply)

1. Demographic changes in the United States
2. The use of international nurses to supplement the nursing shortage in the United States
3. The influence of immigration on health services
4. The influence of herbal supplements being used

Back 113

1. Demographic changes in the United States
3. The influence of immigration on health services

The demographic changes in the overall population of the United States and the influence of immigration on health services are two major reasons for the immense need for culturally focused nursing care.

Hint 113

Ch 18

Front 114

A client who has a French mother and an Italian father is described as having a ___ identification.

1. Bicultural
2. Diversity
3. Subculture
4. Acculturation
5. Assimilation

Back 114

1. Bicultural

Bicultural is used to describe a person with dual patterns of identification who crosses two cultures, lifestyles, and sets of values.

Hint 114

Ch 18

Front 115

A client who is homosexual is described as having:

1. Biculturalism
2. Acculturation
3. Diversity
4. Subculture
5. Assimilation

Back 115

3. Diversity

Diversity refers to the fact or state of being different. Many factors account for diversity: race, gender, sexual orientation, culture, ethnicity, socioeconomic status, educational attainment, religious affiliation, and so on.

Hint 115

Ch 18

Front 116

The involuntary process of ___ occurs when people adapt to or borrow traits from another culture.

1. Biculturalism
2. Acculturation
3. Diversity
4. Subculture
5. Assimilation

Back 116

2. Acculturation

Acculturation is the involuntary process that occurs when people adapt to or borrow traits from another culture.

Hint 116

Ch 18

Front 117

If a citizen of Japan permanently moves to America, then ___ may occur when that individual becomes an American citizen.

1. Biculturalism
2. Diversity
3. Assimilation
4. Subculture
5. Acculturation

Back 117

3. Assimilation

Assimilation is the process by which an individual develops a new cultural identity. It means the person becomes similar to the members of the dominant culture.

Hint 117

Ch 18

Front 118

If a nurse caring for a Chinese client orders rice for every meal without consulting the client, the nurse may be:

1. Prejudiced
2. Discriminatory
3. Stereotyping
4. Racist

Back 118

3. Stereotyping

Stereotyping is assuming that all members of a culture or ethnic group are alike, instead of unique individuals.

Hint 118

Ch 18

Front 119

Using the HEALTH traditions model, which of the following would be considered an example of spiritual and mental health?

1. Avoiding persons who can cause illnesses
2. Special foods and drinks
3. Acupuncture
4. Exorcism

Back 119

4. Exorcism

Exorcism is considered both a mental and spiritual method of maintaining health, protecting health, and restoring health.

Hint 119

Ch 18

Front 120

Complementary and alternative medicines (CAM) are being used more frequently and are becoming more socially acceptable. What is one example of a CAM therapy?

1. Massage
2. Antibiotics
3. Electric shock therapy
4. Chicken soup

Back 120

1. Massage

Massage is an example of complementary and alternative medicine (CAM) that is being used as an alternative to Western medical treatment.

Hint 120

Ch 18

Front 121

While caring for a Latin American client who cannot speak or understand English, the nurse recognizes that she will need a ___ in order to care for the client.

1. Family member
2. Translator
3. Representative
4. Interpreter

Back 121

4. Interpreter

An individual who mediates spoken or signed communication between people speaking different languages, without adding, omitting, or distorting material from one language to another.

Hint 121

Ch 18

Front 122

While caring for a diverse cultural population, the nurse must recognize that cultural beliefs and behaviors may lead to:

1. Sterotyping
2. Ethnocentricity
3. Placing of the nurse's culture to others
4. Being confusing regarding the many values and beliefs of different cultures

Back 122

1. Sterotyping

Stereotyping is assuming that all members of a culture or ethnic group are alike. Stereotyping that is unrelated to reality may be based on racism or discrimination.

Hint 122

Ch 18

Front 123

Identify which nursing interventions would be beneficial in communication with clients that have limited knowledge of English. (Select all that apply)

1. Use slang words, limited medical terminology, and no abbreviations
2. Speak slowly, in a respectful manner, and at a normal volume
3. Use nonverbal communication, which uses silence, touch, eye movement, facial expressions, and body posture that is acceptable to that particular culture
4. Ask a member of the client's family, especially a child or spouse, to act as interpreter
5. Address the client, not the interpreter

Back 123

2. Speak slowly, in a respectful manner, and at a normal volume
3. Use nonverbal communication, which uses silence, touch, eye movement, facial expressions, and body posture that is acceptable to that particular culture
5. Address the client, not the interpreter

Health beliefs and practices, family patterns, communication style, space and time orientation, and nutritional patterns may influence the relationship between the nurse and the client who have different cultural backgrounds. Avoid slang words and do not use a member of the client's family to act as an interpreter because the client may not want the family to know about his condition.

Hint 123

Ch 18

Front 124

Campinha-Bacote's model of cultural competence is based on a framework that integrates transcultural nursing, medical anthropology, and multicultural counseling. Identify 3 of the 5 constructs of this model of cultural competence.

1. Cultural awareness
2. Cultural appearance
3. Cultural desires
4. Cultural skills
5. Cultural experiences

Back 124

1. Cultural awareness
3. Cultural desires
4. Cultural skills

Nurses are encouraged to integrate cultural skills, encounters, desires, awareness, and knowledge. Methods to obtain the integration include in-services, community events that entertain other cultures, and by reviewing professional nursing journals that include cultural awareness topics.

Hint 124

Ch 18

Front 125

The end result of data collection and analysis is:

1. Carrying out the plan of care
2. Collecting and then analyzing the data
3. Identifying actual or potential health concerns
4. Identifyng the client's response to care

Back 125

3. Identifying actual or potential health concerns

The identification of the actual or potential health problems of the client is the end result of the data assessment.

Hint 125

Ch 12

Front 126

Identify the nursing diagnosis from the following medical diagnoses.

1. Fever of unknown origin
2. Pancreatitis
3. Potential for sleep-pattern disturbances
4. Congestive heart failure

Back 126

3. Potential for sleep-pattern disturbances

The potential for sleep-pattern disturbances is a nursing diagnosis while the other three are considered medical diagnoses.

Hint 126

Ch 12

Front 127

The purpose of a nursing diagnosis is to:

1. Define taxonomy of nursing language
2. Promote taxonomy of nursing language
3. Identify a client's problem plus etiology
4. Establish a set of principles

Back 127

3. Identify a client's problem plus etiology

The client's problem statement consists of the diagnostic label plus etiology, which is the causal relationship between a problem and its related or risk factors.

Hint 127

Ch 12

Front 128

Choose the appropriate activities that the nurse may perform during the diagnosing component of the nursing process. (Select all that apply)

1. Compare data against current nursing standards
2. Obtain a nursing health history
3. Cluster or group the data to generate a tentative hypothesis
4. Review the client records and nursing literature
5. Identify gaps and inconsistencies in the data

Back 128

1. Compare data against current nursing standards
3. Cluster or group the data to generate a tentative hypothesis
5. Identify gaps and inconsistencies in the data

These are part of the diagnosing component in the nursing diagnosis.

Hint 128

Ch 12

Front 129

One of the nursing functions during the diagnosing phase of the nursing process is to:

1. Clarify all inconsistencies in the data before making inferences
2. Identify Gordon's functional health patterns and compare with the client
3. Review the literature and review professional journals and textbooks
4. Document the health assessment in a specific form

Back 129

1. Clarify all inconsistencies in the data before making inferences

Clarifying the gaps and inconsistencies in the data is one of the three continuous and sequential activities involved in the diagnostic process

Hint 129

Ch 12

Front 130

Readiness for Enhanced Parenting is an example of which type of diagnosis?

1. Wellness diagnosis
2. Health-seeking diagnosis
3. Two-part diagnosis
4. Three-part diagnosis

Back 130

1. Wellness diagnosis

Some diagnostic statements, such as wellness diagnoses and syndrome nursing diagnoses, consist of a NANDA label only.

Hint 130

Ch 12

Front 131

Which of the following nursing diagnostic statements is correct?

1. Fluid replacement related to fever
2. Impaired skin integrity related to immobility
3. Impaired skin integrity related to ulceration of sacral area
4. Pain related to severe headache

Back 131

2. Impaired skin integrity related to immobility

This statement is considered a two-part statement and lists the diagnosis with the related factors and characteristics.

Hint 131

Ch 12

Front 132

How does the nurse begin with a diagnostic label for a collaborative problem?

1. Readiness for Enhanced Spiritual Well-Being
2. Alteration of Respiratory Status
3. Potential Complication for Pneumonia: Atelectasis
4. Impaired Respiratory System

Back 132

3. Potential Complication for Pneumonia: Atelectasis

A collaborative problem is a type of potential problem that nurses manage using both independent and physician-prescribed interventions.

Hint 132

Ch 12

Front 133

The PES format for writing a nursing diagnosis is used for which of the following?

1. Actual nursing diagnoses
2. Potential nursing diagnoses
3. Risk for nursing diagnoses
4. Wellness diagnoses

Back 133

1. Actual nursing diagnoses

The basic three-part nursing diagnosis statement is called the PES format and includes the problem, etiology, and signs and symptoms. The signs and symptoms have been identified, and the PES system in ideal for beginning nursing students.

Hint 133

Ch 12

Front 134

Choose the correct example of a qualifier.

1. Syndrome
2. Potential
3. Deficient
4. Risk for

Back 134

3. Deficient

Qualifiers are words that have been added to some NANDA labels to give additional meaning to the diagnostic statement.

Hint 134

Ch 12

Front 135

Identify and select the advantages of using a taxonomy of nursing diagnoses. (Select all that apply)

1. A taxonomy of nursing diagnoses would promote a classification system or set of categories for a single or set of principles for professional nurses
2. A taxonomy of nursing diagnoses can be used by physicians to define diagnostic nursing terminology
3. A taxonomy of nursing diagnoses enhances the professional practice of the nurse in generating and completing a nursing care plan
4. A taxonomy of nursing diagnoses consists of nursing diagnoses for a single principle or set of principles that were developed by other nursing professionals

Back 135

1. A taxonomy of nursing diagnoses would promote a classification system or set of categories for a single or set of principles for professional nurses
3. A taxonomy of nursing diagnoses enhances the professional practice of the nurse in generating and completing a nursing care plan
4. A taxonomy of nursing diagnoses consists of nursing diagnoses for a single principle or set of principles that were developed by other nursing professionals

A taxonomy is a classification or set of categories arranged based on a single principle or set of principles. The members of NANDA include staff nurses, clinical specialists, faculty, directors of nursing, deans, theorists, and researchers. The group has currently approved more tht 170 nursing diagnoses labels for clincal use and testing. Physicians do not use nursing diagnoses in their practice.

Hint 135

Ch 12

Front 136

Identify the components of a nursing diagnosis. (Select all that apply)

1. Related factors
2. Risk factors
3. Problem
4. Definition
5. Defining characteristics
6. Medical conditions

Back 136

1. Related factors
2. Risk factors
3. Problem
4. Definition
5. Defining characteristics

A nursing diagnoses has three components and consists of all of the above except the medical conditions. A medical diagnosis is made by a physician and refers to a condition that only a physician can treat.

Hint 136

Ch 12

Front 137

"Client will walk to end of hallway without assistance by Friday" is an example of a:

1. Long-term goal
2. Short-term goal
3. Nursing intervention
4. Rationale

Back 137

2. Short-term goal

Short-term goals are useful for clients who require health care for a short time and for those who are frustrated by long-term goals that seem difficult to attain and who need the statisfaction of achieving a short-term goal.

Hint 137

Ch 13

Front 138

"Client will ambulate 20 yards without assistance in 8 weeks" is an example of a:

1. Long-term goal
2. Short-term goal
3. Nursing intervention
4. Rationale

Back 138

1. Long-term goal

Long-term goals are often used for clients who live at home and have chronic health problems and for clients in nursing homes, extended care facilities, and rehabilitation centers.

Hint 138

Ch 13

Front 139

The nurse instructs a newly diagnosed diabetes client on an 1800-calorie ADA diet. This is which type of nursing intervention?

1. Independent intervention
2. Dependent intervention
3. Collaborative intervention
4. Variable intervention

Back 139

1. Independent intervention

These are activities that nurses are licensed to initiate on the basis of their knowledge and skills.

Hint 139

Ch 13

Front 140

The nurse instructs the client on turning, coughing, and deep breathing q 2 hours. What is the relationship of nursing interventiions to problem status?

1. Health promotion interventions
2. Treatment interventions
3. Prevention interventions
4. Observation interventions

Back 140

3. Prevention interventions

Prevention interventions prescribe the care needed to avoid complications or reduce risk factors.

Hint 140

Ch 13

Front 141

The RN needs to assign a person to insert a Foley catheter on a client. To whom can she delegate this task?

1. Unlicensed personnel with limited training
2. A licensed practical/vocational nurse
3. The physician
4. The client's daughter

Back 141

2. A licensed practical/vocational nurse

They have the necessary skills and training to insert Foley catheters.

Hint 141

Ch 13

Front 142

Planning consists of which component?

1. Reassess the client
2. Analyze data
3. Select nursing interventions
4. Determine the nurse's need for assistance

Back 142

3. Select nursing interventions

Selecting nursing interventions based on the assessment findings and nursing diagnosis is the next step in the nursing process.

Hint 142

Ch 13

Front 143

Consider the following nursing diagnosis: "Altered nutritional status, less than body requirements related to inability to feed self." What is an example of a short-term goal for this client?

1. The client will eat 75% of his meals by Friday (September 20) with the use of modified eating utensils to feed self with minimal assistance
2. The client will learn about nutritious meal planning as exhibited by choosing one correct menu
3. The client will acquire competence in managing cookware designed for handicapped clients
4. The client will learn preparation techniques that are quick and easy to manage

Back 143

1. The client will eat 75% of his meals by Friday (September 20) with the use of modified eating utensils to feed self with minimal assistance

This is a short-term nursing goal. It is useful for clients who require health care for a short period of time and clients who are frustrated by long-term goals that seem difficult for them to attain and who need the satisfaction of completing a short-term goal.

Hint 143

Ch 13

Front 144

The nurse admitted a client in active labor to the labor and delivery wing of the hospital. When does the planning for client care start?

1. After the physician has delivered the baby
2. After the admissions process
3. When the client is discharged to the postpartum unit
4. During the initial meeting

Back 144

4. During the initial meeting

On the intial contact with the client, the nursing assessment begins and continues throughout the hospital stay, with reassessment during the stay and after the nursing intervention.

Hint 144

Ch 13

Front 145

Which of the following is part of the permanent client record?

1. Nursing protocols
2. Client care plan
3. Procedures for client care
4. The nurse's notebook of daily notes to herself

Back 145

2. Client care plan

The client care plan is a permanent part of the record.

Hint 145

Ch 13

Front 146

In caring for a client with stage 4 pressure ulcers on the coccyx, the nurse is to turn the client every 2 hours while in bed. What part of the nursing process is being carried out?

1. Assessment
2. Diagnosis
3. Implementation
4. Evaluation

Back 146

3. Implementation

Implementation of the nursing care plan is part of the nursing process to achieve the goals and/or outcomes. Reassessment continues at this time to see if the interventions are working effectively. The plan of care may be altered at any time during the client's stay at the facility as needed.

Hint 146

Ch 13

Front 147

The benefits of a nursing intervention classification system are: (Select all that apply)

1. Helps demonstrate the impact that nurses have on the health care delivery system
2. Assists educators to develop curricula that better articulates with clinical practice
3. Standardizes and defines the knowledge base for nursing curricula and practice
4. Facilitates the appropriate selection of a nursing intervention and communication of nursing treatments to other nurses and other providers
5. Promotes the development of a reimbursement system for nursing services

Back 147

1. Helps demonstrate the impact that nurses have on the health care delivery system
2. Assists educators to develop curricula that better articulates with clinical practice
3. Standardizes and defines the knowledge base for nursing curricula and practice
4. Facilitates the appropriate selection of a nursing intervention and communication of nursing treatments to other nurses and other providers
5. Promotes the development of a reimbursement system for nursing services

The benefits of specific nursing interventions enable nursing professionals to provide anticipated changes in the clients.

Hint 147

Ch 13

Front 148

A taxonomy of nursing outcome statements were developed to describe measurable states, behaviors, or perceptions to respond to which part of the nursing process?

1. Nursing assessments
2. Nursing interventions
3. Nursing goals
4. Nursing outcomes

Back 148

2. Nursing interventions

A taxonomy of nursing outcome statements, the Nursing Outcome Classification (NOC) has been developed to describe measurable states, behaviors, or perceptions that respond to nursing interventions. Each has a definition, a measuring scale, and indicators.

Hint 148

Ch 13

Front 149

Evaluation of the client's health care while the client is still receiving care from the agency is called a:

1. Retrospective audit
2. Audit
3. Concurrent audit
4. Peer review

Back 149

3. Concurrent audit

A concurrent audit is the evaluation of a client's health care while the client is still receiving care from the agency.

Hint 149

Ch 14

Front 150

Basic nursing interventions are based on:

1. Scientific knowledge, nursing research, and evidence-based practice
2. Creative thinking and intuition
3. Physician's orders
4. Client's wishes and nursing research

Back 150

1. Scientific knowledge, nursing research, and evidence-based practice

Nursing interventions are based on scientific knowledge, nursing research, and evidence-based practice. The nurse implements the interventions and evaluates the desired outcomes. Based on this evaluation, the plan of care is modified or continued.

Hint 150

Ch 14

Front 151

Which of the following is the fifth and last phase of the nursing process?

1. Evaluating
2. Assessment
3. Planning
4. Implementing
5. Diagnosing

Back 151

1. Evaluating

Evaluating is a planned, ongoing, purposeful activity in which clients and health care professionals determine the client's progress toward achievement of goals/outcomes and the effectiveness of the nursing care plan.

Hint 151

Ch 14

Front 152

The nurse documents that the goal or desired outcome was met, partially met, or not met. What part of the evaluation statement is the nurse documenting?

1. Supporting data
2. Collecting data
3. Finale
4. Conclusion

Back 152

4. Conclusion

Conclusions are drawn when the nurse uses judgments about the goal achievement status. The nurses determine whether the care plan needs to be modified.

Hint 152

Ch 14

Front 153

While implementing the plan of care for the client, the nurse should: (Select all that apply)

1. Supervise unlicensed support personnel that provide care to the client
2. Complete every task for the client including bathing, measuring intake and output, and room cleaning services
3. Complete a retrospective audit
4. Supervise and direct the physician providing care
5. Evaluate the client's reactions to the planned interventions

Back 153

1. Supervise unlicensed support personnel that provide care to the client
5. Evaluate the client's reactions to the planned interventions

One of the steps during the implementation of the plan of care is to supervise delegated care of unlicensed personnel such as nursing assistants or patient care technicians.

Hint 153

Ch 14

Front 154

What is meant by the nurse using interpersonal skills?

1. These skills include problem solving, decision making, critical thinking, and creativity
2. These skills include all of the activities, verbal and nonverbal, that people use when interacting directly with one another
3. These skills include manipulating equipment, giving injections, bandaging, etc
4. These skills include leadership management and delegation

Back 154

2. These skills include all of the activities, verbal and nonverbal, that people use when interacting directly with one another

Interpersonal skills are the combination of verbal and nonverbal activities persons use when interacting with one another.

Hint 154

Ch 14

Front 155

In which of the following situations does the nurse need assistance with implementing the nursing interventions?

1. A nurse applying Buck's traction for the fifth time
2. A nurse who has just begun working in the hospital
3. A nurse who turns the client in bed without the client experiencing discomfort
4. A nurse transferring a bilateral amputee from bed to chair

Back 155

4. A nurse transferring a bilateral amputee from bed to chair

The nurse would need assistance during transfer of a bilateral amputee in order to provide safe care. The nurse needs to be holistic, implement safe care, adapt activities to the individual clients, and clearly understand the needed nursing interventions.

Hint 155

Ch 14

Front 156

What are two nursing phases that overlap each other in the nursing process?

1. Assessing; diagnosing
2. Planning; implementing
3. Implementing; evaluation
4. Evaluating; assessing

Back 156

4. Evaluating; assessing

Evaluating and assessing are two nursing phases of the nursing process that often overlap because the nurse is evaluating the plan of care and assessing the client's responses to it.

Hint 156

Ch 14

Front 157

The nurse writes an evaluation statement after determining whether a nursing goal or client outcome has been met. What are the two parts in an evaluation statement?

1. Conclusion and implementation
2. Conclusion and supporting data
3. Implementation and summary
4. Implementation and data analysis

Back 157

2. Conclusion and supporting data

The evaluation statement consists of two parts, conclusion and supporting data. The conclusion is a statement that the goal or desired outcome was met, partially met, or not met. Supporting data are the list of clients responses that support the conclusion. Reexamining the client care plan is a process of making decisions about problem status and critiquing each phase of the nursing process.

Hint 157

Ch 14

Front 158

A quality-assurance (QA) program evaluates and promotes excellence in the health care provided to clients. Select the three components of care that are reviewed during this process from the following:

1. Structure evaluation
2. Process evaluation
3. Outcome evaluation
4. Internal processes and external agency evaluations

Back 158

1. Structure evaluation
2. Process evaluation
3. Outcome evaluation

A quality assurance program is an evaluation which includes the consideration of the structures, processes, and outcomes of nursing care. Quality improvement is a philosophy and process internal to the institution, and does not rely on inspections by an external agency.

Hint 158

Ch 14

Front 159

The client is a chronic carrier of infection. To prevent the spread of the infection to other clients or health care providers, the nurse emphasizes interventions that do which of the following?

1. Eliminate the reservoir
2. Block the portal of exit from the reservoir
3. Block the portal of entry into the host
4. Decrease the susceptibility of the host

Back 159

2. Block the portal of exit from the reservoir

Blocking the movement of the organism from the reservoir will succeed in preventing the infection of any other persons. Since the carrier person is the reservoir and the condition is chronic, it is not possible to eliminate the reservoir.

Hint 159

Ch 31

Front 160

The most effective nursing action for controlling the spread of infection includes which of the following?

1. Thorough hand cleansing
2. Wearing gloves and masks when providing direct client care
3. Implementing appropriate isolation precautions
4. Administering broad-spectrum prophylactic antibiotics

Back 160

1. Thorough hand cleansing

Since the hands are frequently in contact with clients and equipment, they are the most obvious source of transmission. Regular and routine hand cleansing is the most effective way to prevent movement of potentially infective materials.

Hint 160

Ch 31

Front 161

In caring for a client on contact precautions for a draining infected foot ulcer, the nurse should perform which of the following?

1. Wear a mask during dressing changes
2. Provide disposable meal trays and silverware
3. Follow standard precautions in all interactions with the client
4. Use surgical aseptic technique for all direct contact with the client

Back 161

3. Follow standard precautions in all interactions with the client

Standard Precautions include all aspects of contact precautions with the exception of placing the client in a private room.

Hint 161

Ch 31

Front 162

When caring for a single client during one shift, it is appropriate for the nurse to reuse which of the following personal protective equipment?

1. Goggles
2. Gown
3. Surgical mask
4. Clean gloves

Back 162

1. Goggles

Unless overly contaminated by material that has splashed in the nurse's face and cannot be effectively rinsed off, goggles may be worn repeatedly.

Hint 162

Ch 31

Front 163

While donning sterile gloves (open method), the cuff of the first glove rolls under itself about 1/4 inch. The best action for the nurse is to:

1. Remove the glove and start over with a new pair
2. Wait until the second glove is in place and then unroll the cuff with the other sterile hand
3. Ask a colleague to assist by unrolling the cuff
4. Leave the cuff rolled under

Back 163

4. Leave the cuff rolled under

It should not be necessary to unroll this small edge of the cuff. The most important consideration is the sterility of the fingers and hand that will be used to perform the sterile procedure.

Hint 163

Ch 31

Front 164

After evaluating the client's chart, the nurse concludes that a 65-year-old client's immunizations are current. What evidence supports this conclusion? (Select all that apply)

1. Last tetanus booster was at age 50
2. Receives a flu shot every year
3. Has not received the hepatitis B vaccine
4. Has not received the hepatitis A vaccine

Back 164

2. Receives a flu shot every year
3. Has not received the hepatitis B vaccine
4. Has not received the hepatitis A vaccine

All adults should receive tetanus boosters every 10 years (or sooner if injured). Flu shots are recommended for all adults over age 50. Only persons at risk need to receive hepatitis A and B vaccines.

Hint 164

Ch 31

Front 165

After teaching a client and family strategies to prevent infection, which statement by the client would indicate effective learning has occurred?

1. "We will use antimicrobial soap and hot water to wash our hands at least three times per day."
2. "We must wash or peel all raw fruits and vegetables before eating."
3. "A wound or sore is not infected unless we see it draining pus."
4. "We should not share toothbrushes but it is ok to share towels and washcloths."

Back 165

2. "We must wash or peel all raw fruits and vegetables before eating."

Raw foods touched by human hands can carry significant infectious organisms and must be washed or peeled.

Hint 165

Ch 31

Front 166

The nurse determines that a field remains sterile if which of the following conditions exist?

1. Tips of wet forceps are held upward when held in ungloved hands
2. The field was set up 1 hour before the procedure
3. Sterile items are 2 inches from the edge of the field
4. The nurse reaches over the field rather than around the edges

Back 166

3. Sterile items are 2 inches from the edge of the field

All items within 1 inch of the edge of the sterile field are considered contaminated because the edge of the field is in contact with unsterile areas.

Hint 166

Ch 31

Front 167

Which of the following means freedom from disease-causing microorganisms?

1. Medical asepsis
2. Asepsis
3. Surgical asepsis
4. Sepsis

Back 167

2. Asepsis

Asepsis is the freedom from disease-causing microorganisms.

Hint 167

Ch 31

Front 168

Which of the following consists primarily of nucleic acid and therefore must enter living cells in order to reproduce?

1. Fungi
2. Bacteria
3. Viruses
4. Parasites

Back 168

3. Viruses

Viruses consist primarily of nucleic acid and therefore must enter living cells in order to reproduce.

Hint 168

Ch 31

Front 169

Inflammation is a local and nonspecific defensive response of the tissues to an injurious or infectious agent. Which of the following is NOT a sign of inflammation?

1. Pain
2. Swelling
3. Redness
4. Fatigue

Back 169

4. Fatigue

Fatigue is not a sign of inflammation.

Hint 169

Ch 31

Front 170

Four commonly used methods of sterilization are moist heat, gas, boiling water, and radiation. Which of the following is the most practical and inexpensive method for sterilizing in the home?

1. Gas
2. Moist heat
3. Radiation
4. Boiling water

Back 170

4. Boiling water

This is the most practical and inexpensive method for sterilizing in the home. The main disadvantage is that spores and some viruses are not killed by this method.

Hint 170

Ch 31

Front 171

A nurse is evaluating a nursing student's understanding of types of infections. Which of the following statements demonstrates a need for further teaching?

1. A local infection is limited to the specific part of the body where the microorganisms remain
2. If the microorganisms spread and damage different parts of the body, it is a systemic infection
3. Acute infections may occur slowly, over a very long period, and may last months or years
4. Nosocomial infections are classified as infections that are associated with the delivery of health care services in a health care facility

Back 171

3. Acute infections may occur slowly, over a very long period, and may last months or years

Acute infections generally appear suddenly or last a short time.

Hint 171

Ch 31

Front 172

Which type of precautions are used for clients known or suspected to have serious illnesses trasmitted by particle droplets larger than 5 microns?

1. Airborne
2. Droplet
3. Contact
4. Connection

Back 172

2. Droplet

Hint 172

Ch 31

Front 173

An antigen is a:

1. Host that produces antibodies in response to natural antigens (i.e., infectious microorganisms) or artificial antigens (i.e., vaccines)
2. Substance that induces a state of sensitivity or immune responsiveness (immunity)
3. Host that receives natural (i.e., from a nursing mother) or artificial (i.e., from an injection of immune serum) antibodies produced by another source
4. Part of the body's plasma proteins

Back 173

2. Substance that induces a state of sensitivity or immune responsiveness (immunity)

Hint 173

Ch 31

Front 174

The CDC recommends antimicrobial hand cleansing agents in all of the following situations EXCEPT:

1. When there are unknown multiple nonresistant bacteria
2. Before invasive procedures
3. In special care units, such as nurseries and ICUs
4. Before caring for severely immunocompromised clients

Back 174

1. When there are unknown multiple nonresistant bacteria

The CDC recommends when there are KNOWN multiple RESISTANT bacteria.

Hint 174

Ch 31

Front 175

Which of the following statements about disinfectants in incorrect?

1. A disinfectant is a chemical preparation, such as phenol or iodine compounds, used on inanimate objects
2. Disinfectants are frequently caustic and toxic to tissues
3. Disinfectants and antiseptics often have similar chemical components, but the disinfectant is a less concentrated solution
4. A disinfectant in an agent that destroys pathogens other than spores

Back 175

3. Disinfectants and antiseptics often have similar chemical components, but the disinfectant is a less concentrated solution

Disinfectants and antiseptics often have similar chemical components, but the disinfectant is a MORE concentrated solution.

Hint 175

Ch 31